Lawmakers Demand Oversight as Medicare Advantage Plans Use AI to Deny Care

The group, led by Rep. Judy Chu (D-Calif.), argues that the reliance on AI for coverage determinations in inpatient hospitals, skilled nursing facilities, and home health settings has led to a surge in repeated denials. In a letter to CMS Administrator Chiquita Brooks-LaSure, the representatives requested a comprehensive audit of how these tools are deployed, specifically asking for data on denial rates, beneficiary characteristics, and whether algorithms are being used to circumvent established health regulations.

Advocacy groups, including Public Citizen and the Center for Medicare Advocacy, have backed the call, characterizing the practice as a profit-driven strategy that prioritizes corporate margins over patient outcomes. Lisa Gilbert, executive vice president of Public Citizen, noted that these mechanisms effectively deny care that would be readily covered under traditional Medicare. Recent reports suggest that Medicare Advantage plans are overcharging taxpayers by as much as $140 billion annually, fueling further criticism from progressive legislators who have long described the privatized program as a fundamentally flawed system. The lawmakers are now pushing for mandatory transparency, requiring insurers to disclose how AI guidance influences their final coverage decisions and whether race or other demographic factors are influencing algorithmic outputs.