Medicare recently announced it will be launching a pilot program that will use AI for prior authorization of select claims to “combat waste, fraud, and abuse.” This program will be rolled out in six states to start, including Washington State. 1 The program is titled WISeR (Wasteful and Inappropriate Service Reduction) Model and will launch in January 2026 and is anticipated to run for six years. The program is said to promote increased efficiency and cost savings.
The program is focused on specific procedures that have been flagged as potentially having “little to no clinical benefit for certain patients and that historically have had a higher risk of waste, fraud and abuse.”2 Importantly for patients with pain, victims of car accidents, and providers who treat them, some of the procedures targeted are electrical nerve stimulator implants, epidural steroid injections for pain management, and cervical fusion procedures.3
The AI model will not focus on inpatient and emergency services and services that “would pose a substantial risk to patients if delayed.” Recommendations for non-payment will be determined by licensed clinicians (humans) who will apply standardized, transparent, and evidence-based procedures to their review.4
Experts and industry leaders have raised concerns that this will lead to higher denial rates for necessary care. The American Medical Association points out that AI tools have been found in some cases to produce rates of denial 16 times higher than is typical.5 Using AI companies instead of claims adjusters to review the claims will only be deemed successful if the program saves money—which in the health insurance context results from denying care. In describing how the AI companies will be compensated, the Center for Medicare Services advises:
“Participants will be rewarded based on the effectiveness of their technology solutions for reducing spending on medically unnecessary or non-covered services. For each selected service, participants will receive a percentage of the reduction in savings that can be attributed to their reduction of wasteful or inappropriate care.”6
This program will not apply to people with Medicare Advantage plans.
This does mean that Medicare participants’ health information will be shared with the AI companies providing these services.
One result of this development will be the requirement for patients and their health care providers to discuss alternate ways of addressing patient care needs. As the full extent of Medicare and AI-approved prior authorizations become clearer, patients and providers will need to be more proactive in order to reduce the potential for delayed care and increased workload for healthcare professionals.
Interestingly, after finishing this article, I then asked AI to write its own article about this topic. Unsurprisingly, it was very positive about the new process.
- https://www.cms.gov/priorities/innovation/innovation-models/wiser ↩︎
- Id.
↩︎ - https://www.cms.gov/files/document/wiser-provider-supplier-guide.pdf
↩︎ - Id.
↩︎ - https://www.hsgac.senate.gov/wp-content/uploads/2024.10.17-PSI-Majority-Staff-Report-on-Medicare-Advantage.pdf
↩︎ - https://www.cms.gov/files/document/wiser-fact-sheet.pdf
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