If he can look at the cases much faster, CMS may not want to pay more for each case because it’s a quicker, easier, and cheaper process for him when using the AI tool. The agency may even want to pay less for each case.

“We may be asking for codes for AI, but those codes may pay us less when we get reimbursed,” he explained. “I think there's a bit of a catch-22, and so I and some of the organizations are thinking how to proceed to ask and advocate for a code. It may be quicker and more accurate and precise, but the value shouldn't be [disregarded].”


Another hurdle is the uncertainty around who is liable when these AI tools are used for clinical decision-making. Is it the fault of the vendor of the technology, the hospital, or the individual provider if things should go wrong?

“At the end of the day, if it comes to M.D. versus AI, who is correct in making a decision?,” asked Pantanowitz. “I've heard of scenarios where it actually puts some M.D.s in a difficult predicament.

For instance, the AI may indicate that something is cancer, but the physician might not agree. If it does result in litigation, it may be revealed that the physician has only seen 20 cases like that in their career, but the AI could be trained on thousands of those types of cases — raising the question of who is more experienced or qualified to diagnose.

Rethinking reimbursement
Shen and Pantanowitz recently co-authored an article in Modern Pathology arguing these challenges require existing reimbursement policies to undergo a reevaluation so that they align with the “innovative nature of ABHS technologies.”

One possible solution is creating new reimbursement codes specifically for ABHS applications, as well as a Medicare payment pathway. That could be done by establishing the software as a service (SaaS) Add-on Policy into Medicare regulation, so that add-on payment options could be available for ABHS through existing reimbursement payment pathways. Another solution could be through pilot programs that implement payment models like episode-based or performance-linked reimbursements.

“I'm always a believer in communication and getting people informed so that all stakeholders understand what's at play,” said Pantanowitz. “[We should have] forums where there's communication and there's data tracking and outcomes are followed. I think that's the solution that's needed.”

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