ICD10monitor February 28, 2024
One of the issues that the Centers for Medicare & Medicaid Services (CMS) addressed in its new rule for Medicare Advantage (MA) plans, CMS-4201-F, was the use of artificial intelligence (AI) and automated protocols to deny care. And obviously, their guidance was that this was not acceptable.
Just to clarify, the MA plans were using AI to predict the length of stay for inpatient rehabilitation facility (IRF) admissions, skilled nursing facility (SNF) care, and home health episodes of care. If the AI program said a patient needed eight days in the SNF, they refused to pay at day 9. CMS explained that before discontinuing coverage, the plan must review the patient’s specific clinical needs and compare that to Medicare coverage...
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