A newly proposed federal bill could strengthen protections against automated Medicare Advantage denials by requiring physician oversight before AI-influenced prior authorization denials are issued.

The Protecting Patients from Automated Denials Act would prohibit Medicare Advantage plans from denying covered services solely on the basis of artificial intelligence. Instead, a qualified physician would be required to independently review and approve each denial.

For nursing homes, this legislation addresses a common challenge: delayed or denied prior authorizations for post-acute care following hospitalization. These delays can disrupt discharges, postpone admissions, and create additional administrative burdens when facilities need to appeal coverage decisions.

If enacted, beginning with plan years on or after January 1, 2027, the bill would require:

• Independent review and approval of AI-related denials by a qualified physician
• Clinical decisions based on the physician's own medical judgment—not AI recommendations alone
• Access for providers to the reviewing physician and their written attestation
• Disclosure when AI was used during the decision-making process
• Record retention for AI-related denials for at least 10 years, along with regular reporting to the U.S. Department of Health and Human Services (HHS)

Timely Medicare Advantage approvals are critical for nursing homes to admit residents, continue therapy, and avoid care interruptions. By requiring greater transparency and physician accountability, the proposed legislation could provide facilities with a clearer path to understanding and appealing coverage denials.

While the bill has not yet been enacted, facilities should continue strengthening documentation of medical necessity, therapy needs, functional limitations, discharge barriers, and physician recommendations to support successful authorization requests.