In a pivotal move, CMS has released updated guidance on November 26, 2024 to ensure Medicare Advantage (MA) plans employing artificial intelligence (AI) uphold equity and compliance with federal regulations.
With AI's growing influence in healthcare, CMS highlights the need for transparency and fairness in its integration within MA services. A proposed revision to 42 CFR §422.112(a)(8) emphasizes the responsibility of MA plans to deliver equitable services, irrespective of whether care decisions are guided by human professionals or AI-based tools.
Key Highlights of the Guidance:
Anti-Discrimination Compliance. MA plans using AI must adhere to Section 1852(b) of the Social Security Act and other applicable regulations, ensuring no discrimination based on health status or other inequitable factors. This aims to protect patients from bias embedded in AI systems.
Person-Centered Care. AI tools must support the delivery of person-centered care, promoting equitable access to necessary services across diverse populations, including those with disabilities or limited income.
Accountability and Oversight. CMS mandates that MA plans using AI conduct annual health equity analyses to identify potential disparities. These evaluations will examine how prior authorization policies and AI-powered decisions affect care delivery, with a focus on avoiding undue delays or denials for vulnerable enrollees.
Broader Impact. The proposed changes are part of CMS's ongoing efforts to reduce barriers to care, improve transparency, and ensure technology-driven solutions like AI enhance access to high-quality healthcare rather than exacerbate inequities.
This guidance aligns with CMS's broader push to strengthen consumer protections, address barriers posed by utilization management tools, and encourage ethical innovation in healthcare technology. By embedding these guardrails, CMS aims to harness AI's potential while safeguarding enrollees from unintended harms caused by biased algorithms or opaque decision-making processes.
For stakeholders in healthcare, this represents a call to action: integrate AI responsibly, prioritize equity, and remain vigilant in ensuring compliance with evolving regulations.
Learn more about the proposed rule here
How Alignmt AI Enables Compliance
Alignmt AI specializes in automating compliance and risk management, offering a tailored platform that supports healthcare enterprises in addressing emerging regulations, such as those outlined by CMS. Here’s how our solution aligns with CMS's objectives:
Bias Auditing & Mitigation: Alignmt AI continuously evaluates and audits AI systems for biases that could impact care delivery, ensuring compliance with CMS anti-discrimination standards.
Regulatory Mapping: Our platform cross-references AI applications with federal requirements (e.g., § 422.112 and § 422.110), providing real-time insights into compliance gaps.
Transparent Documentation: We generate comprehensive reports that MA plans can use to demonstrate adherence during audits or regulatory reviews.
Equity Impact Analysis: Alignmt AI includes tools to assess and mitigate disparities in healthcare outcomes resulting from AI decisions, ensuring equitable service delivery.
Training Modules: Equip teams with the knowledge to develop, deploy, and manage AI systems responsibly in line with CMS guidelines.
What This Means for MA Plans
CMS’s push for equitable AI use presents both a challenge and an opportunity for MA plans. By leveraging solutions like Alignmt AI, organizations can not only achieve compliance but also lead the charge in promoting health equity. These efforts are likely to be scrutinized further as CMS incorporates these measures into quality improvement programs and Star Ratings.
To learn more about how Alignmt AI can streamline your compliance processes, contact us today. Together, we can ensure AI is a force for good in healthcare delivery.
Comments