Managed Care - Healthcare Empowered

Summary of article from Sheppard Mullin Richter & Hampton LLP, by Lynsey Mitchel:

California’s SB 1120 bill aims to regulate the use of artificial intelligence (AI) in managed care, requiring AI tools to be fair, non-discriminatory, and based on a patient’s medical history and individual circumstances. The bill aligns with the Centers for Medicare and Medicaid Services (CMS) rules, which allow the use of AI in coverage determinations as long as the AI complies with all applicable rules and does not solely dictate decisions. Other states like Georgia, New York, Oklahoma, and Pennsylvania have similar bills, focusing on regulator review and disclosure of AI use. Various states have also adopted the National Association of Insurance Commissioners’ guidelines to mitigate the risk of adverse outcomes from AI use. Payors are urged to monitor their AI tools closely to reduce the risk of legal issues arising from improper service denials.

From Squire Patton Boggs, by Bevan Blake:

In response to the continued growth of managed care in government-sponsored health plans over the last several years, the Office of Inspector General (“OIG”) of the U.S. Department of Health and Human Services (“HHS”) introduced a new “Strategic Plan for Oversight of Managed Care for Medicare and Medicaid.”

A majority of Medicare beneficiaries are enrolled in a Medicare Advantage Plan.
It is estimated that the share of beneficiaries enrolled in Medicare Advantage Plans will increase to 60% in ten years.
For Medicaid, almost seventy-five percent (75%) of beneficiaries are now enrolled with comprehensive Managed Care Organizations.

The Strategic Plan identifies three areas of focus for OIG: (1) promoting access to care for enrollees, (2) providing comprehensive financial oversight, and (3) promoting data accuracy.
Promoting Access to Care: OIG will review plans and assess whether they meet network adequacy standards.
Financial Oversight: OIG will work with managed care plans to identify and prevent fraud within the plans and to ensure the accuracy of the risk-adjusted capitated payments provided to managed care plans.
Data Accuracy: OIG wants provider identifiers on Medicare Advantage encounter data so it can provide oversight of the program, and avoid losses caused by enrollees who are enrolled in two different states or managed care organizations.