Algorithm Regulation: U.S. Takes Action on Medicare Advantage Coverage

The Centers for Medicare and Medicaid Services (CMS) will implement new rules next year to restrict the use of predictive technology tools by Medicare Advantage plans in making coverage decisions. These tools, such as UnitedHealthcare's NaviHealth, use algorithms to predict patients' care needs and discharge dates. However, patients, providers, and advocates have raised concerns that the predictions often align with the date coverage is cut off, even if further treatment is necessary. The new rules aim to ensure that coverage decisions are based on individual circumstances and reviewed by healthcare professionals, rather than relying solely on algorithms. Critics question how the rules will be enforced, while CMS states that audits and enforcement actions may be taken for noncompliance.