Medicare pilot program to use AI for pre-approval of medical procedures
A new Medicare pilot program will require prior authorization for certain medical procedures, using AI to approve or deny coverage
A new Medicare pilot program will require prior authorization for certain medical procedures, using AI to approve or deny coverage
A new Medicare pilot program will require prior authorization for certain medical procedures, using AI to approve or deny coverage
A new program from the will require prior authorization, or pre-approval, from insurers for certain medical procedures. The government says the program will test whether it can reduce waste, fraud, and abuse and will start rolling out next year in Ohio, Oklahoma, Arizona, New Jersey, Texas, and Washington.
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The , which provides millions with government health insurance for people 65 and older and those with disabilities. Some medical services that will face the extra prior authorization step include — treatments the government says that could cost billions in unnecessary taxpayer dollars each year.
But the most controversial part of the program is how the government will make decisions on what is and isn't covered. The program contracts private AI firms to review cases, which, experts say, could lead to inappropriate denials. The AI firms have an incentive to say "no" to coverage because of the direct payments they make for each denial. it could lead to many patients being denied services they are legally entitled to.
If a claim is denied, patients may be responsible for the costs, so doctors advise patients to be their own best advocates, know their rights, research, and, most importantly, appeal denied claims.
Experts say the new prior authorization requirement may make traditional Medicare less attractive, potentially pushing more people to switch to Medicare Advantage plans. Medicare Advantage generally costs the government more per person than traditional Medicare, which could end up shifting money around as opposed to saving any money.
Experts also say the program could lead to patients receiving treatments that are easiest for approval rather than those best for their health. This concern has led some doctors and lawmakers to protest what they say is a lack of transparency in the government's approach to the pilot program.
