Bipartisan Lawmakers Urge CMS to Limit AI Tools’ Use by Medicare Advantage Plans, Including for Nursing Home Care

Over 50 lawmakers from both chambers of Congress are urging the Centers for Medicare and Medicaid Services (CMS) to increase scrutiny and regulation of artificial intelligence tools used by Medicare Advantage plans.

In a letter addressed to CMS Administrator Chiquita Brooks-LaSure, the legislators expressed deep concerns over the use of AI algorithms by MA plans to guide coverage decisions, especially for prior authorizations for medical treatments and rehabilitative care to sick Medicare Advantage patients.

The lawmakers highlighted instances where AI-driven tools allegedly led to denials of care, contradicting assessments made by health care providers, and noted a lawsuit filed against UnitedHealth Group for pressuring employees to use such tools in care denial.


Representative Judy Chu (D-Calif.), Representative Jerry Nadler (D-N.Y.), Senator Elizabeth Warren (D-Mass.), and Senator Mike Braun (R-Ind.) are among the signatories of the letter sent Tuesday. They emphasized the need for CMS to establish a rigorous oversight framework that ensures the integrity and accuracy of AI and algorithmic tools used by MA plans.

“Plans continue to use AI tools to erroneously deny care and contradict provider assessment findings,” the letter reads. “We believe more detailed guidance is needed to protect access to care for Medicare beneficiaries and improve clarity for providers.”

The legislators proposed several measures for CMS to consider, including the implementation of a formal approval process for reviewing AI tools and their underlying algorithms. They also called for a comprehensive assessment of the existing AI tools deployed by MA plans to determine their compliance with regulatory standards and their impact on patient care.


“We believe CMS must take a proactive stance in monitoring the utilization of AI and algorithm-driven tools by MA plans,” the letter stated. “Absent a prohibition on the use of such tools altogether, CMS should limit their use until a systematic evaluation can be conducted on how these tools are impacting care.”

Lawmakers also expressed skepticism about the transparency of the inputs used in these AI systems, which they argued complicates efforts to gauge the accuracy and regulatory compliance of the decisions made.

Nisha Hammel, Vice President of Reimbursement Policy & Population Health at the American Health Care Association and National Center for Assisted Living (AHCA/NCAL) applauded the bid by lawmakers, stating concerns regarding truncated care at SNFs due to overuse of AI tools in favor of clinician led coverage decisions.

“Skilled nursing providers have struggled, and continue to struggle, with Medicare Advantage coverage decisions that are based solely on AI algorithms,” Hammel said. “Relying on automated systems alone and making decisions without speaking to the person directly or consulting medical professionals can unnecessarily end coverage sooner than is medically necessary.”

Officials for LeadingAge, the largest advocacy groups for nonprofit long-term care providers, echoed these concerns in a statement to Skilled Nursing News, highlighting the burdens created by Medicare Advantage plans. 

“[LeadingAge members] have first-hand experience of Medicare Advantage (MA) plans’ inappropriate use of prior authorization to deny, shorten and limit MA enrollees’ access to medically necessary Medicare benefits,” said Katie Smith Sloan, president and CEO of LeadingAge. “And the volume of denials – and flouting of Medicare rules – is increasingly common, thanks to plans’ growing reliance on artificial intelligence (AI) and algorithmic software to make these determinations.”

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