Denied by AI: How Medicare Advantage plans use algorithms to cut off care for seniors in need [View all]

[usonian]

https://www.statnews.com/2023/03/13/medicare-advantage-plans-denial-artificial-intelligence/
Tons here.
• "Medicare Advantage" makes it possible.
• "The Algorithm" makes decisions

Patients thrown under the bus.
Long and worth reading.

NaviHealth started making its sales pitch to Medicare Advantage plans: Let us manage every piece of your members’ care for the first 60 to 90 days after they are discharged from the hospital, and we’ll all share in any savings.

The sweetener was the technology. One of the company’s core products is an algorithm called nH Predict. It uses details such as a person’s diagnosis, age, living situation, and physical function to find similar individuals in a database of 6 million patients it compiled over years of working with providers. It then generates an assessment of the patient’s mobility and cognitive capacity, along with a down-to-the-minute prediction of their medical needs, estimated length of stay, and target discharge date.

...

In interviews, doctors, medical directors, and hospital administrators described increasingly frequent Medicare Advantage payment denials for care routinely covered in traditional Medicare. Many said their attempts to get explanations are met with blank stares and refusals to share more information. The black box of the AI has become a blanket excuse for denials.

“They say, ‘That’s proprietary,’” said Amanda Ford, who facilitates access to rehabilitation services for patients following inpatient stays at Lowell General Hospital in Massachusetts. “It’s always that canned response: ‘The patient can be managed in a lower level of care.’”

"But the algorithm!!!"