Health Law Highlights

The Intersection of Artificial Intelligence and Utilization Review

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.