Physicians speak out against payers’ growing use of AI to deny imaging requests
Physicians are speaking out against health insurers’ use of artificial intelligence to deny radiology and other services.
Heart imaging specialists are sharing reports of payers auto-denying coverage of cardiac PET (positron emission tomography) and instead pushing for coronary CT, with no regard for medical evidence. Amid these problems, the American Society of Nuclear Cardiology sponsored a resolution at the recent AMA meeting, calling for greater scrutiny around AI-based utilization reviews.
“This issue is deeply concerning to physicians, and it has been presented a number of times to the AMA House of Delegates,” Suman Tandon, MD, a cardiac imager at St. Francis Hospital and Heart Center, in Rosyln, New York, and ASNC representative to the American Medical Association, told Radiology Business at the meeting. “The use of AI is making the issue of prior authorization worse, not better."
Resolution 226 calls for the American Medical Association to advocate for state and federal oversight and possible legislation to address this issue. ASNC and others want to ensure that payers use AI to review requests in a way that is safe, transparent and unbiased. The related AMA reference committee heard “mixed” feedback on the resolution, according to association documents. Testimony in support stressed “growing concern” about AI’s use in care denials. Several physicians shared personal experiences in which AI-driven denials of prescription renewals or prior authorization requests has led to “patient harm and distress.”
However, physicians also testified that key asks of the resolution are addressed by existing AMA policy, which the association is already actively advocating on this issue. As such, the House of Delegates ended up partially adopting the resolution as proposed. ASNC highlighted the decision in a news update published June 16.
Legislation to address this issue
Meanwhile. Dr. Tandon and colleagues also touted the nuclear society’s support for the Improving Seniors’ Timely Access to Care Act. The bill was reintroduced by bipartisan senators in May and gained widespread support from the U.S. House in the previous Congress. It aims to streamline the “often cumbersome and time-consuming” task of approving prior authorization requests for imaging and other services under the Medicare Advantage program.
Numerous medical societies have endorsed the Timely Access to Care Act, including the American College of Radiology. The Society of Interventional Radiology announced its support for the bill in a June 6 news update, and the American Society for Radiation Oncology (ASTRO) did the same last month.
“Prior authorization is a persistent and problematic thorn in the side of American healthcare. Patients and physicians—not insurance companies—should be at the center of treatment decisions,” Howard M. Sandler, MD, chair of the ASTRO Board of Directors, said in a statement.
Separately, the AMA passed another resolution at its annual meeting in Chicago, which ended June 11. The policy calls for the opposition of payers using utilization management systems to limit patients’ access to necessary services. Amid “rampant” consolidation in the insurance industry, large payers can “dominate” the definition of what is deemed necessary, using this decision to deny access to care and payment for services.
“Recently, insurers have claimed this unchecked power because of consolidation, cutting physicians out of the process and driving up patients’ costs,” said pediatrician Toluwalase Ajayi, MD, a member of the AMA Board of Trustees.
Dave Fornell contributed to this report.
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.