Artificial Intelligence in Medicare Audits: Part I

CMS launches healthcare outcomes challenge.

Expect more artificial intelligence (AI) in healthcare in 2020. We will see AI used primarily in diagnostics and auditing. In each of these areas, AI promises to impose drastic changes on society. As these changes reverberate through organizations, old work patterns will be disrupted. In addition, legal and regulatory protocols will be forced into constant revision, as responsibility for decision-making and the liability that comes with it shifts from people to machines.

This will raise two important issues. First, who will take responsibility when harmful mistakes are made? Second, how can organizations victimized by machine-driven auditing defend themselves against faceless algorithms?

The AI Market is Growing Rapidly
The AI market is growing quickly. A market of only around $16 billion in 2017 should reach almost $200 billion by 2025. This year, it should pass the $80 billion mark. Some have placed the CAGR at almost 40 percent. Capital investment is pouring in at the rate of more than $2 billion per quarter, and new AI chipsets are entering the market.

We know that exciting growth projections such as this should be taken with a grain of salt. Definitions on what constitutes a “market,” and what type of programming actually is “true” AI may provide some fuzziness to the precision. But even accounting for the inevitable errors that accompany any approximation and claims of seeing into the future, still we can see that AI is one of the major technology forces that will shape this decade. In the 21st century, we might say the smartphone shaped the first decade, social media the second, and AI will shape the third.

AI is Providing Proven Benefits in Healthcare
In the healthcare sector, it long has been a dream of researchers to replace doctors with computers. The drive behind this was not so much anti-doctor, but rather the desire to harness technology, especially telecommunications, to disperse the benefits of medical knowledge throughout the world, to places where there were no doctors available. This thinking started in the 1980s, and the term used was “telemedicine.” 

Progress has been rapid. Google’s DeepMind recently published a paper in Nature indicating that AI can be used to predict acute kidney injury (AKI) before it happens.

The Federal Drug Administration (FDA) has been supervising the testing of AI systems in healthcare, and has been approving systems that meet its tough standards. AI systems now can read and interpret medical images. For example, there are currently AI systems that can help doctors interpret MRIs of the heart, CT scans of the head, and photos of the back of the eye. The AI systems are not replacing doctors, but are speeding up their work by making initial interpretations and making recommendations that then are ratified by a real doctor. Other AI systems have been approved that can read mammograms and identify breast cancer.

FDA approvals have increased steadily. One algorithm was approved in 2014, four in 2016, and five in 2017. In 2018, eleven were approved, including the first AI for medical diagnosis that requires no input from a human clinician.

Most of the FDA sign-offs have been for use of AI in radiology, where 22 systems have been approved. Cardiology follows with 12 approvals. Other areas of AI work include oncology with five, endocrinology with six, and psychiatry with four. Those areas are the leaders in application of AI in medicine. The rest of the approvals granted by the FDA are distributed across geriatrics, neurology, orthopedics, emergency medicine, ophthalmology, and pathology.

AI groupies chirp about a bright future. They paint a rosy future in which mundane medical chores are done by algorithm. Doctors will get more time to spend with patients. Life will be good.

Is there a Dark Side to AI?
Some predictions are rosy, others are cautionary. Some worry that when one takes the human out of decision-making, one also takes out the humanity. Other observers worry about massive unemployment effects, particularly amongst the ranks of white-collar employees. Anyone visiting the remarkable beacon of innovation, the AmazonGo stores, can see the future. There are no cashiers. The only persons allowed to enter the store are ones with a smart phone running the Amazon app linked to a credit card. Only one or two persons are present stocking the shelves. It is not too far-fetched to assume they too soon will be replaced by robots.

The United Nations First Committee on Disarmament is worried about the development and proliferation of AI-powered “autonomous weapons systems,” which will use algorithms will decide whether or not to pull the trigger.

AI sometimes makes mistakes. A diagnosis might change depending on irrelevant factors, such as the brand of the MRI machine.

What to Expect with AI in 2020?
Look for more government regulation of AI in 2020. We can safely predict that some state governments will restrict how businesses may use AI. Recent complaints about some healthcare algorithms have charged that they have bias. We can detect an emerging consensus that AI must be “fair” to everyone. We can safely predict that this standard will lead to a new wave of litigation, including class-action suits against algorithms.

Another AI trend to watch is the Centers for Medicare & Medicaid Services (CMS) AI Health Outcomes Challenge. Given the alleged losses of $21 billion per year in waste and fraud in Medicare, CMS has been instructed through an executive order to investigate the use of AI for auditing. Late last year, CMS issued an RFI asking for help. The goal is to change the “pay and chase” model of auditing to a predictive system. Rather than employing the old system of using algorithms to comb through data ferreting out fraud and abuse, CMS wants AI to prevent making bad payments in the first place.

As part of the Challenge, CMS recently selected 25 participants. Some are from the entrenched Washington Beltway aristocracy: Booz Allen Hamilton, IBM, Northrop Grumman, etc. These are major systems integrators with legendary technical skills. The participants also include a few from academia, including the University of Virginia, Northwestern, and Columbia University. If the technology is developed, then deep learning and neural networks will be used to predict adverse events and unplanned admissions to skilled nursing facilities and hospitals. According to the schedule, seven finalists will be announced in April. In September, a winner will get $1 million in seed money. Stay tuned in 2020 for more news on these developments.

AI is the future of auditing, healthcare, and many other aspects of society. You may wish to pull out that old copy of 2001: A Space Odyssey, and reacquaint yourself with HAL 9000.

Programming Note: Listen to Edward Roche report on use of AI in Medicare audits during the next live edition of Monitor Mondays, Feb. 10, 10-10:30 a.m. EST.

Facebook
Twitter
LinkedIn

Edward M. Roche, PhD, JD

Edward Roche is the director of scientific intelligence for Barraclough NY, LLC. Mr. Roche is also a member of the California Bar. Prior to his career in health law, he served as the chief research officer of the Gartner Group, a leading ICT advisory firm. He was chief scientist of the Concours Group, both leading IT consulting and research organizations. Mr. Roche is a member of the RACmonitor editorial board as an investigative reporter and is a popular panelist on Monitor Mondays.

Related Stories

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

The Cost of Ignoring Risk Adjustment: How HCCs Impact Revenue & Compliance

The Cost of Ignoring Risk Adjustment: How HCCs Impact Revenue & Compliance

Stop revenue leakage and boost hospital performance by mastering risk adjustment and HCCs. This essential webcast with expert Cheryl Ericson, RN, MS, CCDS, CDIP, will reveal how inaccurate patient acuity documentation leads to lost reimbursements through penalties from poor quality scores. Learn the critical differences between HCCs and traditional CCs/MCCs, adapt your CDI workflows, and ensure accurate payments in Medicare Advantage and value-based care models. Perfect for HIM leaders, coders, and CDI professionals.  Don’t miss this chance to protect your hospital’s revenue and reputation!

May 29, 2025
I050825

Mastering ICD-10-CM Coding for Diabetes and it’s Complications: Avoiding Denials & Ensuring Compliance

Struggling with ICD-10-CM coding for diabetes and complications? This expert-led webcast clarifies complex combination codes, documentation gaps, and sequencing rules to reduce denials and ensure compliance. Dr. Angela Comfort will provide actionable strategies to accurately link diabetes to complications, improve provider documentation, and optimize reimbursement—helping coders, CDI specialists, and HIM leaders minimize audit risks and strengthen revenue integrity. Don’t miss this chance to master diabetes coding with real-world case studies, key takeaways, and live Q&A!

May 8, 2025
2025 Coding Clinic Webcast Series

2025 ICD-10-CM/PCS Coding Clinic Update Webcast Series

Uncover critical guidance. HIM coding expert, Kay Piper, RHIA, CDIP, CCS, provides an interactive review on important information in each of the AHA’s 2025 ICD-10-CM/PCS Quarterly Coding Clinics in easy-to-access on-demand webcasts, available shortly after each official publication.

April 14, 2025

Trending News

Featured Webcasts

The Two-Midnight Rule: New Challenges, Proven Strategies

The Two-Midnight Rule: New Challenges, Proven Strategies

RACmonitor is proud to welcome back Dr. Ronald Hirsch, one of his most requested webcasts. In this highly anticipated session, Dr. Hirsch will break down the complex Two Midnight Rule Medicare regulations, translating them into clear, actionable guidance. He’ll walk you through the basics of the rule, offer expert interpretation, and apply the rule to real-world clinical scenarios—so you leave with greater clarity, confidence, and the tools to ensure compliance.

June 19, 2025
Open Door Forum Webcast Series

Open Door Forum Webcast Series

Bring your questions and join the conversation during this open forum series, live every Wednesday at 10 a.m. EST from June 11–July 30. Hosted by Chuck Buck, these fast-paced 30-minute sessions connect you directly with top healthcare experts tackling today’s most urgent compliance and policy issues.

June 11, 2025
Open Door Forum: The Changing Face of Addiction: Coding, Compliance & Care

Open Door Forum: The Changing Face of Addiction: Coding, Compliance & Care

Substance abuse is everywhere. It’s a complicated diagnosis with wide-ranging implications well beyond acute care. The face of addiction continues to change so it’s important to remember not just the addict but the spectrum of extended victims and the other social determinants and legal ramifications. Join John K. Hall, MD, JD, MBA, FCLM, FRCPC, for a critical Q&A on navigating substance abuse in 2025.  Register today and be a part of the conversation!

July 16, 2025

Trending News

Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →

CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24