Huge congratulations to HLPC Faculty Director Carmel Shachar, Amy Killelea, and Sara Gerke, whose article “AI And Health Insurance Prior Authorization: Regulators Need To Step Up Oversight” made the Top 10 Health Affairs Forefront Articles of 2024!!
Artificial intelligence (AI)—a machine or computer’s ability to perform cognitive functions—is quickly changing many facets of American life, including how we interact with health insurance. AI is increasingly being used by health insurers to automate a host of functions, including processing prior authorization (PA) requests, managing other plan utilization management techniques, and adjudicating claims. In contrast to the Food and Drug Administration’s (FDA’s) increasing attention to algorithms used to guide clinical decision making, there is relatively little state or federal oversight of both the development and use of algorithms by health insurers.
Recently, the Centers for Medicare and Medicaid Services (CMS) recently issued its Final Rule on Interoperability and PA. While this rule aims to create more transparency on PA criteria and denials, it does not regulate how such decisions are made, such as with or without AI. Industry has taken some important steps toward self-regulation, but there is a growing need for additional mechanisms for accountability and oversight of these algorithms.
In this Forefront article, we focus on the use of AI in PA in particular, which we define as the process an insurance plan uses to make a pre-treatment coverage decision according to clinical criteria used to determine if the service is medically necessary. We will also note suggestions policy makers should consider for addressing these challenges.
A huge thank you to the Health Affairs team!
