AMA targets downcoding, AI licensure; Jacksonville pharmacy owner indicted in $51M fraud; drug-response gene variants found in every participant — Morning Medical Update

AMA targets downcoding, says AI can't hold a physician license

Delegates also want physicians shielded from liability for declining an AI tool's advice.

Physician delegates at the American Medical Association (AMA) Interim Meeting in Orlando, Florida, voted to strengthen opposition to insurer downcoding, in which payers reduce the level of a billed service and pay less for it.

The AMA supports legislative guardrails that would prohibit automatic downcoding without clinical record review, require clear notice and explanations when claims are downcoded and establish meaningful appeal processes.

Data cited in a resolution at the meeting estimated that algorithmic downcoding costs family physician practices $28,000 to $74,000 per physician each year. Insurers including Cigna have said their coding reviews align with AMA guidelines and affect a small share of physicians.

Delegates also adopted policy Nov. 9 stating that artificial intelligence (AI) cannot be granted physician licensure, professional titles or certification to practice medicine.

The policy calls for AI tools to be used within physician-led teams at the direction of the treating physician, and for liability protections for physicians who choose not to use an AI tool or follow its recommendation. AMA President Willie Underwood III, M.D., M.Sc., M.P.H., FACS, said patients “deserve to know who is responsible for their care.”

Jacksonville pharmacy owner indicted in $51M health care fraud

Prosecutors say the pharmacy used false HIV diagnosis codes to get claims paid.

Charlie Bernard Griffin III, 61, of Jacksonville, Florida, has been charged in a 31-count federal indictment with health care fraud and money laundering in a scheme that drew about $51 million in reimbursements from Medicare, Medicaid and private insurers, the U.S. Attorney's Office for the Middle District of Florida announced Nov. 12. Ethelbert Chinenye Nwanegbo, 47, an accountant from St. Johns, Florida, is charged in the same indictment with money laundering. Each defendant faces up to 20 years in prison on each count.

Prosecutors allege Griffin's pharmacy, First Coast Community Development, paid a marketing company $200 for each paid referral for HIV medications. Marketers set up tents in low-income areas offering free government-sponsored cellphones in exchange for personal and health insurance information, which the pharmacist used to generate HIV prescriptions that a nurse practitioner authorized without evaluating the patients.

To make sure claims were paid, the pharmacy allegedly used a diagnosis code falsely indicating HIV or a sexually transmitted disease, which was recorded in patients' medical records. Griffin received about $14 million in proceeds, prosecutors said. The marketing company owner, the pharmacist and the nurse practitioner were charged separately and have agreed to plead guilty. An indictment is an allegation, and the defendants are presumed innocent until proven guilty.

Every participant carried a drug-response gene variant

An NIH study found thousands of new variants in genes that shape how patients respond to statins, SSRIs and clopidogrel.

A study of nearly 100,000 participants in the National Institutes of Health's (NIH) All of Us Research Program identified thousands of new variants in 16 pharmacogenes, which influence how the body responds to prescription drugs. Every participant carried at least one variant in those genes, and 1 in 4 had taken a medication the variants could affect. The affected drugs include selective serotonin reuptake inhibitors (SSRIs), statins, chemotherapy and the blood thinner clopidogrel.

The paper, published Nov. 11 in Science Translational Medicine, drew on a more diverse mix of ancestries than earlier databases such as the U.K. Biobank, turning up variants those studies missed.

Senior author Philip Empey cautioned that genetics cannot be declared the sole cause of a poor drug response. Barriers to clinical use remain, including that many people have not had their genomes sequenced and physicians may not know how specific variants affect the drugs they prescribe. STAT has more.