AI initiated prior auth denials for post-acute services: On October 17 a report was released by the Senate Permanent Subcommittee on Investigations regarding the relationship between high denial rates for prior authorization by Medicare Advantage (MA) insurers, and the usage of AI. The report showed that denials for post-acute care services such as skilled nursing facilities or long-term acute care hospitals were denied at a significantly higher rate than other services. The report also concluded that AI was used in these decisions. The report recommends that CMS gather and provide more detailed data on the denials, specifically requesting the denials be separated by service category to determine which services have the highest rates of denial. The subcommittee also wants to evaluate the influence AI and predictive technology has on humans choosing to deny a service.
On a positive note: Representative Monica De La Cruz (R-TX-15) introduced the Diabetes Prevention Program Reauthorization Act (HR 10039) to Congress on October 25. The bill supports access to preventive care for type 2 diabetes, specifically through lifestyle changes. Rep. Lou Correa (D-CA-46) provides bipartisan support for this bill that will reauthorize and increase funding for the National Diabetes Prevention Program. This program has been successful in reducing the development of type 2 diabetes for those who are over the age of 60.
Yvette M. Salas MSN, CRRN