US Government Tightens Rules on AI in Healthcare Coverage Decisions

The Medicare & Medicaid Services issues new guidelines to prevent AI from solely determining patient coverage, addressing concerns over fairness and accuracy.

CMS clarifies that AI cannot be the sole basis for healthcare coverage decisions, aiming to ensure decisions are based on individual patient circumstances.
Recent lawsuits against UnitedHealth and Humana highlight the misuse of AI tools like nH Predict in denying Medicare Advantage plan coverage.
The new memo mandates that healthcare decisions must consider the patient's medical history, physician recommendations, and clinical notes.
CMS warns against the potential for AI to exacerbate discrimination and bias in healthcare decisions.
Non-compliance with the new guidelines could result in warning letters, corrective action plans, monetary penalties, and sanctions for insurers.