Pappas Raises Concern About Improper Use of AI by Medicare Advantage Providers

This week, Congressman Chris Pappas (NH-01) called on the Administrator of the Centers for Medicare and Medicaid Services (CMS) to exercise strong oversight over the use of artificial intelligence (AI) in Medicare Advantage prior authorization determinations. Congressman Pappas cited reports of improper claims denials by Medicare Advantage plans and highlighted the concerns of Medicare enrollees that the use of AI to evaluate claims may lead Medicare Advantage providers and other health care providers to abuse the prior authorization process. 

In the letter Congressman Pappas highlighted existing issues with Medicare Advantage claims, noting that, “In 2018 the Department of Health and Human Services’ Office of Inspector General (OIG) reported ‘widespread and persistent problems related to denials of care and payment in Medicare Advantage.’ In 2022 the OIG reported that 13% of prior authorization requests denied by MA plans actually met Medicare coverage rules. It is unacceptable that claims that would have likely been approved under traditional Medicare have been denied through misuse of prior authorization by MA organizations.”

Pappas added, “Given the existing reports of unjust denials, I am concerned that the use of AI in claims processing could further exacerbate MA prior authorization abuse and denials,” and called on CMS to exercise proper oversight over the use of AI by Medicare Advantage providers.

The text of the letter can be found here and below:

Dear Administrator Brooks-LaSure,

Thank you for your ongoing work toward prior authorization oversight and reform. I write to express concern about how the rising use of artificial intelligence (AI) and algorithmic software may lead to abuse of the prior authorization process by Medicare Advantage (MA) organizations.

In 2018 the Department of Health and Human Services’ Office of Inspector General (OIG) reported “widespread and persistent problems related to denials of care and payment in Medicare Advantage.” In 2022 the OIG reported that 13% of prior authorization requests denied by MA plans actually met Medicare coverage rules. It is unacceptable that claims that would have likely been approved under traditional Medicare have been denied through misuse of prior authorization by MA organizations.

Given the existing reports of unjust denials, I am concerned that the use of AI in claims processing could further exacerbate MA prior authorization abuse and denials. Additionally, if HHS does not exercise proper oversight regarding the use of AI in MA prior authorization determinations, I am concerned about the precedent it may set for the use of AI in the Medicaid and Department of Veterans Affairs health care systems. 

Thank you for your attention to this request. I look forward to continuing to work with you to improve the health and well-being of the American people.

Sincerely,