This is Jacob I sent with the Becker payer issues podcast. Here's your bi weekly industry news briefing for June 20 sixth. Lawmakers are pushing Cms to do more to prevent misuse of artificial intelligence by Medicare advantage plans. A group of 51 lawmakers signed a letter to Cms administrator, Chi Brooks asu on June 20 fifth. Asking the agency to implement more stringent oversight regarding the technology.
In November, families of 2 United health Medicare advantage members sued the company, alleging that Nav Health an Ai algorithm owned by Opt, wrongfully denied the members post acute care. An Opt spokesperson previously told backers that the product is not used to make coverage
determinations. In their letter, the lawmakers wrote, they remain concerned about M plans use of prior authorization, specifically their ongoing use of artificial intelligence, algorithm software to guide coverage decisions. Plans continue to use Ai tools to erroneous deny care and contradict to provider assessment findings. In February, Cms published guidance on how Ai
can be used by M plans. In its guidance, the agency said payers can use out to support coverage decisions, but is their responsibility to ensure that an algorithm or Ai based tool is compliant with Cms requirements. M plans can use algorithms only to predict length of stay for post acute services, and not as the basis for terminating coverage. At a February hearing, experts told members of the Senate Finance committee that Cms is guidance may not be clear enough to prevent misuse of.
In their letter, the lawmakers urged Cms to implement more specific guidance around how plans can use Ai. The legislators are asking the agency to create an approval process. Us to vet new Ai tools used by insurers and to prohibit the use of Ai tools and coverage decisions until the agency has completed Asus systematic review. Well Blue Shield of California has fired a top executive for allegedly lying about her medical credentials.
Tasha Lara La was previously the interim vice president, Chief Medical Officer and the medical director of medical management and accreditation, and Blue Shield. The company told Backers, it has it had learned a former employee, quote, misrepresented her name and licensure, and so they reported the matter to law enforcement. Miss lara La is listed as a doctor of os homeopathic medicine in an archived version
of blue builds corporate leadership page. There is no record of her in the licensed date In the licensing database of the Os path Medical Board of California The individual... She did not treat patients and her role was primarily administrative. The company told Becker that because this is an active fraud investigation as well as
a personnel matter. They cannot discuss more details, but they are confident the authorities will conduct a thorough investigation and they are committed to supporting that effort. Well the Us Supreme Court has declined to hear Home Depot challenge to a 2670000000.00 up settlement with Blue Cross Blue Shield companies, ending a legal saga over alleged and competitive behavior the Dates valor back to 20 12.
The court also rejected a related challenge for a 667000000 dollar fee award for the attorneys who were involved with the settlement. Now Bc cbs members first brought this case back in 20 12, alleging that Bc cbs companies conspired to divide up markets to avoid competing with each other, thereby driving up costs for consumers. In 20 20, Bc cbs companies and the Association reached that 2700000000.0 dollar settlement, in which Bc admitted to no wrongdoing.
That settlement mandated the Bc companies drop an association rule that required 2 thirds of national net revenues from health plans and related services to come from blue branded products. Another rule, the settlement struck down had required large employers to work with the blue insurer that offers coverage where the employer is. Headquartered so that Bc cbs companies could avoid competing with 1 another for large contracts. A federal judge approved that settlement in 20 22.
But later that year Home Depot and other Lit filed a challenge to the agreement, arguing that the settlement did not achieve the lawsuits original objective. Which was to stop Bc cbs companies from receiving exclusive geographic branding rights. A Circuit court of appeals upheld the settled in 20 23 and Home Depot appealed to the supreme court in March of 20 24. We'll post acute care provider accent care has named Chris Main as president of its home
health division. Mister Main had been with Opt since 20 14, and hem most recently served as president of the company's California business. His prior roles at Opt California included chief administrative officer and Coo. And prior to Opt, he spent 10 years with Da, which was purchased by Opt in 20 19. Other executive, big moves, B Wynn has been named president of Carol On health, the health services arm of El Health. Miss Wayne has
been with El since 20 20. And before that, she was chief strategy and innovation officer at Bc of North Carolina. Caroline was launched in 20 22 when Anthem rebranded to El, consolidating the company's portfolio of Non insurance capabilities and services under a single name. And finally, Arkansas attorney general, Tim Griffin has filed a lawsuit against pharmacy benefit managers, opt and express scripts for their alleged role in
enabling the opioid epidemic in the state. He He said, quote, pill by pill and dollar by dollar, Pb enabled the opioid epidemic in Arkansas. Today, we begin the process of holding them accountable for their roles in a crisis. That has ravaged our state, a crisis they helped cause contributed to and further. The lawsuit alleges that the United Health and Cy that subsidiaries, increased opioid use by placing opioids on
lower formula tiers. They operated online retail pharmacies that dispensed morphine milligram equivalents of opioids and that they were aware of the epidemic, but they failed to act. Now a spokesperson for opt told back ers that Opt did not cause the opioid crisis or make it worse and that the company will defend itself in this litigation up takes the opioid epidemic seriously and has taken a comprehensive
approach to fight this issue. A specific amount of damages isn't being sought in the lawsuit, but the attorney general is asking for full restitution to the state, and an abatement of the alleged public nuisance that was created. If you like the latest health insurance industry news delivered a straight inbox every morning. Subscribe to the Becker payer issues e news letter on our website, matt becker payer dot com.