Lawmakers Challenge AI-Driven Care Denials in Medicare Advantage

The letter sent to Centers for Medicare and Medicaid Services Administrator Chiquita Brooks-LaSure highlights a growing pattern where automated tools contradict clinical assessments. Lawmakers point to a class-action lawsuit against UnitedHealth Group as a primary example, alleging the company pressured staff to align rehabilitation stays with outcomes predicted by an AI tool known as nH Predict. Critics argue these practices prioritize corporate profit margins over the health outcomes of seniors and individuals with disabilities.

While CMS issued guidance in February stating that AI cannot supersede standards for medical necessity, patient advocacy groups maintain that oversight remains insufficient. Lisa Gilbert of Public Citizen described the reliance on these systems as a sacrifice of patient needs to corporate greed. David Lipschutz from the Center for Medicare Advocacy echoed these concerns, noting that algorithmic software frequently leads to the premature termination of care. Legislative efforts to reform these private plans have gained momentum, following reports that Medicare Advantage overcharged the federal government by $82 billion in the last year alone.