Medicare Advantage plans increasingly are using artificial intelligence and related tools to determine which care is approved for coverage.
Algorithms and artificial intelligence determine care in many plans and are driving denials of coverage to new highs, according to a study by STAT.
The case for using AI is that the tools can process more data than a human can. That allows care to be personalized and delivers better outcomes at lower cost.
The case against AI is that it uses historic and average data to make recommendations. It doesn’t adjust for individual circumstances and details. Critics also suggest that the standards of some AI programs are more stringent than Medicare’s coverage rules.
Sometimes the problem isn’t the AI itself but how a plan uses AI. While the results of AI are meant to be suggestive, apparently in some plans the AI recommendations are prescriptive and followed without deviation.
Advantage plan members of course can appeal a denial of care. But if the plan upholds the original finding, a beneficiary must resort to a multi-year appeal process. In the meantime, the beneficiary has to go without the care or pay for it and hope to be reimbursed later.
The main point of contention in care in Advantage plans is nursing home care, also known as post-acute care and skilled nursing care, that’s provided after a hospital stay. Medicare will pay for up to 100 days of nursing home care after a hospital stay of at least three days. The care often is to help someone who is recovering from a major surgery or illness. They don’t need all the services of a hospital but need rehabilitation or help doing the activities of daily living for a while before they can go home.
The STAT study said that denials of nursing home care by Advantage plans increased in recent years and that most denials of nursing home care that are appealed eventually are overturned by the plan itself or an independent body that reviews Medicare appeals.