Artificial intelligence will soon get an opinion on approval of or rejecting medical care treatments

When taking a page from the Playbook book for the Special Insurance Industry, the Trump administration will launch a program next year to know the amount of money that the artificial intelligence algorithm can save the federal government by refusing to care for medical care patients.

The experimental program, designed to get rid of wasted “low -value” services, promotes the federal expansion of an unpopular process called prior mandate, which requires patients or someone in their medical team to obtain insurance approval before conducting some procedures, tests and prescriptions. This will affect Medicare patients, doctors and hospitals who are interested in them, in Arizona, Ohio, Oklahoma, New Jersey, Texas, and Washington, starting from January 1 and continuing until 2031.

The move sparked eyebrows between politicians and politicians. The traditional version of Medicare, which covers 65 and above adults and some people with disabilities, have mostly avoided in advance. However, it is widely used by private insurance companies, especially in the Medicare feature market.

The timing was surprising: the pilot was He announced in late JuneMohamed Oz, director of the Medicare & Medicaid service centers, said only a few days after the Trump administration revealed a voluntary effort by private health insurance companies to renew and reduce its own use of prior licensing, which leads to “great delay.”

“It eats the public’s confidence in the health care system,” Oz told the media. “It is something we cannot afford in this administration.”

But some critics, such as Vinay Rathi, Ohio State University and Political Researcher, accused the Trump administration of sending mixed messages.

On the one hand, he said that the federal government wants to borrow cost reduction measures used by private insurance. “On the other hand, slapping them on the wrist.”

Representative Suzan Delbine, a Washington democracy, said that administration officials “talk about both sides of their mouth.” “It is anxiety.”

Patients, doctors and other legislators also criticized what they see Delay or competition tacticsWhich can slow down or prevent access to care, It causes irreparable harm and even death.

“The insurance companies have placed in their slogan that they will take the money of the patients and then make the most cursed to deny that they give to the people who provide care,” said Representative Greg Murphy, a Republican in North Carolina and a urologist. “This continues in every board of directors of the insurance company.”

Insurance companies have long been arguing that pre -mandate reduces fraud and waste, as well as prohibiting potential damage. Public discontent dominated the denial of news insurance in December, when Shooting the death of the CEO of UNITEDHEALTHCAR He led many to wipe his alleged killer as a popular hero.

The audience hates the practice on a large scale: it is nearly three quarters of the respondents. The previous mandate believed was a “big” problem in A survey in July published by KFFIt is a non -profit health information that includes KFF Health News.

In fact, Oz said during his press conference in June that “street violence” prompted the Trump administration to take over the issue of prior delegation reform in the private insurance industry.

However, the administration expands the use of pre -mandate in Medicare. “Both initiatives” serve the same goal as to protect patients and medical care dollar. “

Questions not answered

the Experimental programIt will test the wise – short for “reducing the inaccurate and inappropriate service” – the use of Amnesty International’s algorithm in making pre -evaluation decisions for some medical care services, including skin alternatives and tissues, cultivating electrical nerve stimulus, and knee endoscopy.

The federal government says that these measures are especially vulnerable to “fraud, waste and abuse” and can be reviewed by prior licensing.

Other procedures can be added to the list. But the services that are in an emergency for internal patients, or “will be a great risk to patients if they are late” will not be subject to the evaluation of the artificial intelligence model, according to the federal announcement.

Although the use of artificial intelligence in health insurance is not new, Medicare was slow to adopt private sector tools. MEDICARE historically used in advance in a limited way, with contractors who have not stimulated the rejection of services. But experts who studied the plan believed that the federal pilot can change this.

Bons told KFF Health News that no medicare request would be rejected before reviewing it by the “qualified human doctor”, and that the sellers “are banned from compensation arrangements related to denial rates.” While the government says the sellers will be rewarded for savings, Bones said there are multiple guarantees “will remove any incentive to deny appropriate careful care.”

“The joint savings arrangements mean that the sellers benefit financially when providing less care,” said Jennifer Brakhen, director of government affairs, a structure that can create a strong incentive for companies to deny the necessary care.

Doctors and politicians say this is only one concern.

Rathi said that the plan “is not fully embodied” and relies on “chaotic and subjective” measures. He said the model ultimately depends on contractors to assess their results, which is a choice that makes the results suspected.

“I am not sure that they know, even, how they will discover whether this helps or harms patients,” he said.

Bons said that the use of artificial intelligence in the medical care pilot will be “subject to strict supervision to ensure transparency, accountability and alignment with medical care rules and the patient’s protection.”

He said: “CMS is still committed to ensuring that supporting the automated tools, not replacing it, is clinically proper decision -making.”

Experts agree that artificial intelligence theoretically capable of expediting a stressful process characterized by delays and denial that can harm patients’ health. Health insurance companies have argued that artificial intelligence removes human error and bias and will provide health care system funds. These companies also insisted that humans, not computers, are ultimately reviewing coverage decisions.

But some scientists suspect that this will happen routinely.

“I think there is also a little ambiguity about what constitutes a” meaningful humanitarian review, “said Amy Kelleya, an assistant professor at the Georgetown Health Insurance Reform Center.

2023 A report published by ProPublica I found that for two months, doctors at CIGNA who reviewed the average payment applications spent only 1.2 seconds in each case.

CIFNA spokesman Justin Sessions told KFF Health News that the company does not use artificial intelligence to deny care or claims. The investigation of the ProPublica referred to “a simple program that relies on programs that helped accelerate payments for doctors for the relatively low -cost joint tests and treatments, and are not operated by artificial intelligence.” “It was not used for the previous license.”

However, the lawsuits filed against major health insurance companies claimed that defective intelligence models undermine the doctor’s recommendations and fail to take into account the unique needs of patients, forcing some people to bear the financial burden to take care of them.

At the same time, a Wiping the published doctors By the American Medical Association in February, I found that 61 % believe that artificial intelligence “increases the rejection of the previous mandate, exacerbates the sick harm that can be avoided and escalated unnecessary waste now and in the future.”

Chris Bond, a spokesman for the AHip Ahip, told Kff Health News that the organization is “unknown” to implement the obligations that were exposed to the government. This includes limiting the scope of prior mandate and ensuring that communications with patients about denial and stabbing are easy to understand.

“This is a pilot”

Medicare Pilot emphasizes the ongoing concerns about the prior mandate and uploading it new.

Although private health insurance companies have been transparent about how they used Amnesty International and their pre -use, political researchers believe that these algorithms are often programmed to deny high -cost care automatically.

“The more expensive, the more likely it will be denied,” said Jennifer Oliva, a professor at the Law College of Indiana, whose work focuses on the organization of artificial intelligence and health coverage.

Oliva explained in a hadith A paper for the Indiana law magazine When the patient is expected to die within a few years, health insurance companies are “driven by dependence on algorithm.” With the passage of time and the patient or his provider is forced to resume denial, the patient’s death is increased during that operation. Oliva said that the longer his stabbing, the less the possibility of paying the health insurance company to pay the claim.

“The first thing to do is make it very difficult for people to obtain high -cost services,” she said.

Carmel Chatshar, director of the teaching staff at the Faculty of Law Center at the Faculty of Law at Harvard University, said that the use of artificial intelligence by health insurance companies is preparing for growth, as the insurance company algorithms are a “organizational blind point” and requires more scrutiny.

She said the wise pilot is a “interesting step” towards the use of artificial intelligence to ensure that the dollars of medical care buy high -quality health care. But the lack of details makes it difficult to determine if it will work.

Politicians are struggling with some of the same questions.

“How is this tested in the first place? How will you make sure that he works and does not deny care or produce higher rates of care?” Delpine asked, from August message signed To Oz with other Democrats who ask for answers about the artificial intelligence program. But the Democrats are not the only anxious.

Murphy, who participated in the presidency of the Republican Doctors Council, admitted that many doctors are concerned that the wise pilot could overcome their practice in medicine if the artificial intelligence algorithm refused the care that the doctor recommended.

Meanwhile, members of the House of Representatives on both sides were supported recently The measure proposed by MP Luis FranklkDemocratic in Florida, to prevent financing for the pilot in the 2026 financial budget of the Ministry of Health and Humanitarian Services.

Murphy said that artificial intelligence in health care here is to remain, but it remains to see whether the wise pilot will save medical care funds or contribute to the problems he already poses through prior abandonment.

Murphy said: “This is a pilot, and I am open to see what will happen with this, but I will always mistake, always on the side that doctors know what is better for their patients.”