H.R. 6361: Ban AI Denials in Medicare Act

This bill, titled the "Ban AI Denials in Medicare Act," aims to address the use of artificial intelligence (AI) and prior authorization practices in the Medicare program. It includes two main provisions:

1. Prohibition of the WISeR Model

The bill prohibits the Secretary of Health and Human Services from implementing a specific payment and service delivery model known as the "WISeR Model." This model was proposed to incorporate prior authorization for certain services within traditional Medicare. Essentially, this provision stops any testing or operationalization of this model which might require doctors to get approval before certain services are provided to patients, thereby potentially delaying care.

2. Limitation on Future Models

The second provision amends existing law governing the Center for Medicare and Medicaid Innovation (CMI). It restricts the Secretary from selecting any future models that would allow prior authorization—especially those that involve the use of AI—under traditional Medicare. This means that, going forward, the government cannot adopt new payment models that would similarly require prior authorization for Medicare services that could involve AI decision-making.

Overall, this legislation seeks to ensure that AI is not utilized within the Medicare framework for denying services through prior authorization processes, aiming to simplify access to healthcare services for Medicare beneficiaries.

Relevant Companies

• CVS - As a major health service provider, CVS could be affected by limitations on prior authorization processes, impacting their operations within Medicare services.
• UNH - UnitedHealth Group, as a significant player in healthcare coverage, may need to adapt its services and policies in response to changes in Medicare payment models that are constrained by this bill.
• ANTM - Anthem Inc. might also be impacted, as any restrictions on authorization processes could result in changes to how they manage Medicare claims and reimbursements.