Protecting Patients from Automated Denials Act
- Sponsor
- Rep. Conaway, Herbert C. [D-NJ-3]
- Committees
- Energy and Commerce Committee (primary)
- Last action
- Jul 16, 2026
Bottom line
This bill aims to ensure human clinical oversight and transparency in Medicare Advantage prior authorization denials that involve artificial intelligence, protecting beneficiaries from purely algorithm-driven decisions.
What it actually does
This bill establishes new requirements for Medicare Advantage (MA) plans regarding the use of artificial intelligence (AI) in denying prior authorization requests. It mandates that any denial based on AI output must undergo review and approval by a qualified physician, who must attest to exercising independent medical judgment. The bill also requires MA plans to provide transparency to providers and beneficiaries, maintain detailed records, and submit quarterly reports to the Secretary of Health and Human Services, who is granted broad audit authority.
Proponents argue
Proponents argue that the bill protects Medicare Advantage beneficiaries from potentially arbitrary or algorithm-driven denials of necessary medical care by ensuring that a qualified physician independently reviews and approves any denial stemming from AI output. They contend it enhances patient safety, improves transparency, and restores trust in the prior authorization process by preventing AI from being the sole arbiter of care decisions.
Opponents contend
Opponents might argue that these requirements could increase administrative burdens and costs for Medicare Advantage organizations, potentially slowing down the prior authorization process and delaying access to care. They may also contend that it could stifle innovation in AI development for healthcare efficiency, as MA plans might be disincentivized from using AI if the oversight requirements are too stringent or costly.
The bill is concise and clearly written, allowing for a quick and straightforward understanding of its core provisions.
Section 2(a), amending Section 1852(o)(1)(A) and (B) of the Social Security Act.
Mandated Human Review and Independent Medical Judgment for AI-Based Denials
This provision requires that any prior authorization denial by a Medicare Advantage plan that is based on artificial intelligence output must first be reviewed and approved by a qualified physician reviewer. This physician must attest that they exercised independent medical judgment, that the denial was not generated or dictated by AI, and that any software used in preparing such denial was used only for administrative purposes.
Supporters argue
Supporters argue this ensures patient safety by preventing algorithms from overriding clinical judgment, safeguarding beneficiaries from potentially erroneous or biased AI decisions. It reintroduces human accountability into a critical healthcare decision-making process.
Critics contend
Critics might contend that this adds an unnecessary layer of bureaucracy, increasing costs and potentially slowing down the prior authorization process, which could delay patient access to care. They may argue that AI can be a valuable tool for efficiency and consistency.
Tradeoffs
Balances the efficiency and data-driven insights offered by AI against the need for human clinical judgment and patient protection in healthcare decisions.
Section 2(a), amending Section 1852(o)(1)(C) and (D) of the Social Security Act.
Enhanced Transparency and Communication for Denials
This provision mandates that MA plans provide the requesting provider with a copy of the physician's attestation, an opportunity to communicate directly with the qualified physician reviewer, and a chance to discuss the clinical basis for the denial. It also requires disclosure to both the individual and the provider that AI was used in the denial process and the National Provider Identifier (NPI) of the reviewing physician.
Section 2(a), amending Section 1852(o)(1)(E) and (o)(2) of the Social Security Act.
Data Collection and Oversight for AI Use in Denials
Medicare Advantage plans are required to maintain detailed records for at least 10 years regarding AI use in denials, including physician reviews and attestations. Furthermore, plans must submit quarterly reports to the Secretary of Health and Human Services detailing all prior authorization denials based on AI output, including attestations and associated algorithms or decision protocols.
Section 2(a), amending Section 1852(o)(3) of the Social Security Act.
Enhanced Federal Oversight of AI in Prior Authorization
This provision grants the Secretary of Health and Human Services broad authority to audit and inspect any use of artificial intelligence by MA plans related to prior authorization requirements. This includes reviewing denial data, attestations, comparing AI outputs to denials, assessing overturn rates, reviewing internal policies, interviewing employees, and examining algorithms or decision protocols.
Section 2(a), amending Section 1852(o)(4)(A) of the Social Security Act.
Broad Definition of Artificial Intelligence
The bill defines "artificial intelligence" by referencing section 5002 of the National Artificial Intelligence Initiative Act of 2020 (15 U.S.C. 9401) and further specifies that it includes technology that produces synthetic content from data patterns, acts autonomously, and interfaces with external systems for decision-making beyond initial training data.
Defines "qualified physician reviewer" as a physician who possesses a current, valid, non-restricted license to practice medicine in the state where the service will be furnished, is board-certified or eligible in a specialty that correlates with the requesting provider's specialty, and has experience practicing in such specialty.
Section 2(a), amending Section 1852(o)(4)(B) of the Social Security Act.
Why it matters:It is standard legislative practice to define terms in a dedicated section. However, the specificity of these requirements is crucial for the practical implementation and impact of the bill.
Case for: Supporters argue these stringent qualifications ensure that the human review of AI-based denials is conducted by genuinely expert and relevant medical professionals, adding credibility and clinical validity to the oversight process.
Case against: Critics might argue that these specific requirements could create a shortage of eligible physician reviewers, particularly in certain specialties or geographic areas, increasing costs and administrative challenges for MA plans.
Estimated impact: Ensures high-quality clinical review, but could increase operational costs and recruitment challenges for Medicare Advantage plans.