Artificial Intelligence (AI) has become a huge part of our daily lives. Through computer
algorithms AI has advanced the ability of human decision making from simple to complex and the impact continues to expand in every aspect of our life. Working with the Centers of Medicaid and Medicare Services (CMS) have been no different and CMS actively utilizes AI when reviewing and approving a Medicare Set Aside and has been ever since early 2024.
Through AI capabilities CMS will be able to (but not limited to):
- Improving efficiency expediting with automation the review process and approving MSA’s with a faster turnaround time.
- Automate the review of medical records and the historical data streamlining workflow and determining more accurate calculations. AI can also determine and collect data that pertains to certain trends in healthcare such as costs, medications and treatments.
- AI is capable of verifying billing codes. Potentially and ultimately reduce overfunding or underfunding of the MSA.
- Fraud detection: AI is capable of detecting anomalies in medical records or billing, identifying potential fraud or abuse in claims.
- According to current CMS guidelines “While AI can be used to assist in Medicare Set-Aside (MSA) reviews, it cannot be the sole basis for a decision, and must always consider individual patient circumstances, medical history, and physician recommendations; essentially, AI can only be used as a supporting tool to analyze data and flag potential issues, with final determinations made by human reviewers based on established Medicare coverage criteria.
So what are the cons?
- Ethically with healthcare there can be privacy issues.
- How do we know the algorithms used are accurate and reliable?
- What are the legal ramifications? Risk of malicious cyberattacks?
- AI systems are expensive and require updating to keep up with advances so how often will this be done?
- Workforce may resist due to job displacement.
In summary, AI is here to stay in the CMS world and with this technology, navigating the
process and protecting your clients will continue to be a challenge. Successful integration will require careful planning, regulatory agreement and stakeholder buy-in.
Marilyn R. Litwin and Michele Earney