Traditional Medicare to pilot use of AI when authorizing procedures

Traditional Medicare has generally avoided the practice known as prior authorization, but KFF Health News has reported that they are now not only considering expanding use of the practice, but also using AI with it. Both doctors and patients have criticized the practice of prior authorization, where insurers require doctors to seek approval for certain procedures before the insurers agree to pay for most or all of the costs associated with those procedures. Insurers use prior authorization to reduce fraud and inappropriate treatments. However, even when the practice is not abused, the extra steps for review and the denials can be very challenging for providers and patients.

While Medicare Advantage plans use prior authorization and private insurers have been known to use AI in their prior authorization reviews, traditional Medicare generally has not. However, as the current administration tries to spend more efficiently, they are piloting the use of AI in conjunction with the practice of prior authorization. This departure from historical norms might allow for some cost savings, but will most likely set Medicare down the path of incurring the same frustrations that patients and doctors have encountered with private insurers.