Artificial intelligence (AI) is changing industries everywhere, and the healthcare sector is no exception. While it can seem overwhelming, understanding how AI is used in Medicare is crucial for seniors and their caregivers. This article will help answer your questions about the current and future state of AI in Medicare, focusing on both the benefits and drawbacks, and what you can do about it.
How AI is used in Medicare
AI is already playing a role in various aspects of Medicare, but focusing on these main areas:
- Coverage decisions or utilization management: AI-powered tools are used by some insurance carriers to determine coverage for certain types of care, including prior authorization of services, such as the length of hospital stays it will cover.
- Eligibility: According to a report in Healthcare Finance News, AI is used to identify Medicare beneficiaries who may also be eligible for Medicaid, helping to ensure individuals receive all the benefits they’re entitled to and carriers and providers receive reimbursements for eligible care.
- Early detection of diseases: A new rule from CMS says that Medicare will allow using AI-powered tools for faster diagnosis of diabetic retinopathy, in this case where early detection can make a real difference in care and outcomes.
How AI could be used in Medicare in the future
The United States Senate introduced the “Medicare Transaction Fraud Prevention Act” that would require Medicare to test AI tools to help detect fraud. This bill would aim to reduce the burden on CMS of handling fraudulent claims. As of August 2024, the bill was referred to the Senate Finance committee.
The benefits of using AI in Medicare
Across all industries, the promise of AI is to reduce time in repetitive and predictable tasks. AI can screen claims and cases far faster than humans, potentially speeding up decision-making and access to care. When used to support the expertise of healthcare providers and insurance carriers, AI can contribute to better and faster decisions for beneficiaries.
What are the negatives of using AI in healthcare?
AI itself is not good or bad, but CMS has policies that state that providers and carriers can’t rely too much on AI for decision-making when it comes to patient care. The Center for Medicare Advocacy’s report on AI-powered tools listed these primary concerns of using AI in Medicare:
- Lack of transparency: Many AI tools use proprietary algorithms, making it difficult to understand the reasoning behind their decisions. This can make it challenging for beneficiaries to appeal denied claims.
- Potential for bias: Studies suggest that AI-powered tools might be biased towards denying care based on the potential for improvement or cost considerations. This conflicts with Medicare policy, which states that home-health benefits should be covered even if the goal is to maintain or slow the decline of a condition.
What you can do about AI in your own healthcare
United Medicare Advisors Insurance Agents don’t use AI to make decisions about plan offerings or coverage for our customers, and we would be open about using those tools. However, AI is becoming more prevalent in Medicare, so you should take steps to protect your healthcare:
- Be your own advocate: Always insist on personalized assessments and recommendations from your doctor. Don’t hesitate to ask questions and seek clarification about any decisions made regarding your care. According to CMS’s policy, “an algorithm that determines coverage based on a larger data set instead of the individual patient’s medical history, the physician’s recommendations, or clinical notes would not be compliant.”
- Know your rights: Familiarize yourself with the process of appealing a Medicare coverage decision. If you believe a decision was made unfairly or based on incorrect information, you have the right to appeal.
The use of AI in Medicare is an evolving landscape. By staying informed and proactive, you can help ensure you receive the best possible care.
