Emma Ziegler (Columbia Law) has posted “AI-Generated Denials: Medical Necessity in Medicare Advantage Today” on SSRN. Here is the abstract:
Medicare Advantage insurers hold vast power over access to care for Medicare beneficiaries enrolled in their plans. Among other things, these insurers make the all-important determination as to whether care is “medically necessary” and thus warrants coverage under Medicare. Recently, these insurers have turned to artificial intelligence to help with these determinations. This trend has had concerning results, exacerbating both inaccuracy and nontransparency in the coverage determination process. This Note overviews the current state of determinations and the role Medicare Advantage insurers play in such determinations. Taking an outcomes-focused approach, it argues that the government must demand greater transparency from these insurers and enhance access to the appeals process for beneficiaries. Such reforms are an important first step in ensuring beneficiaries have access to the care they are entitled to.