How AI could disrupt the future of health care regulations [PODCAST]

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We dive deep into the evolving role of artificial intelligence in health care with Muhamad Aly Rifai, a practicing internist and psychiatrist. We explore how AI is not only shaping clinical care but also transforming the enforcement of health care regulations. With a focus on the ethical dilemmas and potential risks of AI in medicine, Muhamad Aly shares his insights on the future of physician autonomy and patient care in an increasingly AI-driven world.

Muhamad Aly Rifai is a practicing internist and psychiatrist in the Greater Lehigh Valley, Pennsylvania.

He discusses the KevinMD article, “The use of artificial intelligence in the enforcement of health care regulations.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at kevinmd.com/podcast. Today, we welcome back Muhamad Aly Rifai. He is an internal medicine physician and psychiatrist. Today’s KevinMD article is “The use of artificial intelligence in the enforcement of health care regulations.” Muhamad Aly, welcome back to the show.

Muhamad Aly Rifai: Thank you for having me.

Kevin Pho: So let’s jump straight into this article. But before talking about it, what led you to write it in the first place?

Muhamad Aly Rifai: So I have been on the receiving end of investigations and prosecutions by the United States Department of Justice and the Department of Health and Human Services, the Office of Inspector General. And during this prosecution, I discovered that the Department of Justice, as well as the Office of Inspector General for the Department of Health and Human Services, had been using artificial intelligence to basically target physicians who are outliers.

Specifically, my area of expertise: Even before the advent of COVID-19 and telehealth, I was doing telehealth, and I was an outlier because there was nobody else that was doing telehealth. I was also doing psychiatric services to rural nursing homes in Pennsylvania. So unfortunately, the precogs of the artificial intelligence caught me because I was an outlier. But the artificial intelligence software did not recognize that I was the only one that was providing these services, and there were no comparators.

So that kind of really prompted me into trying to dig deeper into the subject of artificial intelligence. And some of the things that I discovered were very shocking, and I detail that in the article.

Kevin Pho: All right. And before talking about that article, for those who aren’t familiar with your story, just tell us what kind of accusations that the Department of Justice levied against you.

Muhamad Aly Rifai: So the Department of Justice indicated that I was billing for services that were not provided. Not that we actually didn’t see the patient; we actually saw the patient. But we provided specialized psychiatric services to severely ill, psychiatrically ill individuals who are in rural nursing homes in Pennsylvania.

The government said that we were just providing the bare-bones services, while in reality, we were providing detailed and very specialized services. And they could not distinguish that. The AI basically picked me up because I was an outlier. I was the only one providing services, and there were no comparators.

Kevin Pho: All right. So let’s talk about your article, and you explore the role of AI in targeting you. So tell us what you found.

Muhamad Aly Rifai: So the United States Department of Justice and the Office of Inspector General for Department of Health and Human Services, as well as the Center for Medicare Services, really have started honing in on the utilization of artificial intelligence. Artificial intelligence is basically just a construct, a computerized construct, a machine-learning construct that mimics human intelligence. And there are multiple versions of artificial intelligence.

But specifically, they were targeting the billing codes. They were sending software to kind of swim in the billing codes and see if they could identify codes that are aberrant, people that are different than others, as well as whether people are doing things that were not appropriate.

Specifically, for example, in my case, they had software that spotted whether there was some billing on deceased patients. And in my case, for example, we had three errors where we had two individuals with the same date of birth, but we billed on the deceased one versus the live one. However, in addition to finding these three ones, the software found an additional ten patients that actually had died before I was born, that had died when I was in kindergarten, that had died when I was in high school. And they charged me or indicated that I billed on those patients, where in reality, I wasn’t even practicing at that time.

Kevin Pho: So when you brought up these rebuttals and inaccuracies, what was the response that you received?

Muhamad Aly Rifai: Received a response of embarrassment and lack of explanation. And actually, the jury was very sympathetic to those findings, and that was one of the factors that they decided to come back with a verdict of not guilty because they realized the inaccuracy of the software that the government was using, and that it was basically 80-90 percent inaccurate, and that it was in its infancy. And this is one of the reasons that made me write about this topic.

Kevin Pho: Now, is your case an outlier scenario? For the most part, when the government uses artificial intelligence to look for potential fraud, is it pretty good in most cases, or is your case the norm?

Muhamad Aly Rifai: My case is the norm. It’s typical that the software, the artificial intelligence, is not ready yet. It hasn’t learned. And I’m in the process of writing an article about another event that happened actually a year before my case, where there was some aberrant billing on urinary catheters.

There were some individuals and companies that billed $3 billion worth of urinary catheters, and the Medicare software failed to recognize that. It was actually individuals from the community that alerted Medicare to that aberrant billing. So the artificial intelligence is not ready yet for prime time, and it’s producing faulty results that are resulting in unjust prosecutions of physicians.

Kevin Pho: Now, do you have any insight as to the technology behind the artificial intelligence, and perhaps an explanation why it’s not as accurate as it should be?

Muhamad Aly Rifai: Sure. So number one, it is in its infancy. So it is still learning. During my prosecution, I learned that one of the companies that is a Medicare contractor that does the audits and utilizes artificial intelligence, a company by the name of Safeguard Services, is actually a subsidiary of a larger company called Peraton, P-E-R-A-T-O-N.

And I discovered that Peraton was actually a contractor for all three-letter agencies, the Federal Bureau of Investigation, the Central Intelligence agencies, and they provided artificial intelligence for tracking terrorism and other security threats, and that they were fashioning that software to be utilized in billing for Medicare services.

[Remark removed by the editor.] So it’s software that is used for other purposes being tailored to probe for billing abnormalities in the Medicare billing system.

Kevin Pho: So if a physician gets caught up in one of these cases where they were falsely accused of something that they didn’t do, what kind of options are they confronted with in terms of next steps?

Muhamad Aly Rifai: They have to look really hard at what was done in terms of the statistical analysis. And we’re seeing that there are cases where they are basically identifying a very small number of aberrant billing that they think is aberrant, and then extrapolating to large numbers.

For example, an example that I gave was the case of Dr. Rajendra Bothra in Detroit, where they actually only reviewed 6 charts. They had 25,000 patients. So they reviewed only 6 charts out of 25,000 patients, and they extrapolated that to the degree that they asked for $455 million back. Dr. Rajendra Bothra was found not guilty after the experts that they brought in kind of uncovered these issues with artificial intelligence being used to conflate and inflate the findings from the Department of Justice.

Kevin Pho: Now, are there any typical areas of medicine or typical cases that are more prone to these types of false AI accusations?

Muhamad Aly Rifai: For example, all physicians that were prosecuted for overprescribing opiates were targeted and were screened using artificial intelligence. And there are now some physicians who were defending themselves by bringing in experts to negate that targeting and to show that they were really not outliers, that they were actually in the norm, and that it was actually the AI that targeted them inappropriately.

And then when you dig into the actual evidence against them, which was built on AI, then you’re able to fight those cases. And some physicians have been able to be found not guilty.

Kevin Pho: So you told your story in our last episode. So for those who didn’t get a chance to listen to it, you were falsely accused by artificial intelligence algorithms. Tell us how long that journey to clear your name was. Tell us the emotional difficulties and how much time and effort it took on your end.

Muhamad Aly Rifai: It’s a very difficult journey and took a lot of work, a lot of hard work, a lot of emotions, a lot of sleepless nights trying to sift through the evidence that the Department of Justice gave us to try to figure out how the software was applied.

And because of my knowledge with computers and because of my expertise as an expert witness, as a psychiatrist, I was able to see the areas, as well as with the help of experts in that field. We were able to spot those aberrancies in the software and how the results were presented by the Department of Justice, and be able to poke holes in that evidence.

But we’re seeing where the target of the Office of Inspector General, the Center for Medicare Services, as well as the Department of Justice, is to implement software where it can predict who is going to overcode. It can predict who is going to cause any issues and then act proactively. So kind of predict crime. And that’s a very dangerous situation that we’re heading into, unfortunately.

Kevin Pho: So what is your solution from the government perspective? Because with the size of our current health care system, there has to be a little bit of automation in terms of sifting out bad actors. Is there a role for artificial intelligence? And if so, tell us your vision in terms of improving its role.

Muhamad Aly Rifai: Sure. So I believe there is a tremendous role for artificial intelligence, but it has to be a well-trained artificial intelligence model. And it also has to have a human backup to verify that the results that are coming out from this artificial intelligence model are not just garbage results, are not garbage data.

In my case, the artificial intelligence model spit out results, and there was nobody that actually got involved to verify that this data is appropriate. They just presented the data in court and got embarrassed in court when we pointed out some of these things.

So I think having individuals who are well-trained, for example, and this is one of the critiques that we had: The Office of Inspector General for Department of Health and Human Services is an organization that investigates Medicare fraud. It has one physician on its staff. It has a staff of 1,600. It has one physician, their chief medical officer. That’s it. There are no other physicians. So involving physicians in that process to be able to validate some of these findings, I think, would be very tremendous.

And I would understand if Medicare came to me and said, “We had several physicians take a look at your billing, and we think it’s inappropriate.” I would understand that. But if you tell me that we had agents who are college graduates, high school graduates, who took a look at your billing, and they think it’s fraudulent, they didn’t understand the nuances of the billing. So I think there’s big room for that, but it needs to be in the right hands.

Kevin Pho: We’re talking to Muhamad Aly Rifai. He is an internal medicine physician and psychiatrist. Today’s KevinMD article is “The use of artificial intelligence in the enforcement of health care regulations.” Muhamad Aly, we’ll end with some of your take-home messages that you want to leave with the KevinMD audience.

Muhamad Aly Rifai: I think artificial intelligence is here to stay, and health systems, as well as individuals who are practicing there, need to be attuned to the fact that they may be perceived as outliers in some of the practices or some of the codes or some of the procedures that they practice. And they need to be able to have their own software where they actually have comparators and see where they stand in comparison with their colleagues.

I think there’s tremendous utility for artificial intelligence, and hopefully, we’ll have further talks about other areas of medicine where artificial intelligence can be very, very helpful.

Kevin Pho: Well, thank you again for sharing your story, time, and insight. Thanks again for coming back on the show.

Muhamad Aly Rifai: Thank you.

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