Concerns rise over Medicare AI prior authorization denials

A new Medicare initiative utilizing Artificial Intelligence (AI) for prior authorization requests, dubbed the Wasteful and Inappropriate Service Reduction (WISeR) Model, has reportedly resulted in inappropriate delays and denials of care for beneficiaries [Medicare Rights Center]. Launched in January of this year, the six-year pilot program by the Centers for Medicare & Medicaid Services (CMS) aims to streamline prior authorization for certain services in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington [Medicare Rights Center].

Unlike traditional Original Medicare, which historically has minimal prior authorization requirements, the WISeR Model introduces an AI-driven system for a limited number of services, including certain pain injections, spinal surgeries, and nerve treatments [Medicare Rights Center]. However, recent records and previous reporting suggest that this model is causing harm to people with Original Medicare by leading to inappropriate denials and increasing provider burden [Medicare Rights Center].

AI's Impact on Patient Care

One significant concern raised by these reports is the potential for increased waiting times for beneficiaries needing procedures [Medicare Rights Center]. Patients navigating the appeals process after an initial denial face delays in receiving necessary medical services. These delays are particularly troubling given that past data indicates many individuals who receive an initial denial may not fully remedy the situation through appeals [Medicare Rights Center].

Flawed Program Design Raises Questions

The design of the WISeR model itself has drawn criticism for potentially having a built-in bias toward denying care [Medicare Rights Center]. The AI companies responsible for making the initial coverage decisions are reportedly compensated more if they block access to medical services [Medicare Rights Center]. While official protocol states that AI decisions are reviewed by human clinicians, studies suggest that these clinicians can be influenced by an initial denial made by the AI system [Medicare Rights Center].

Potential for Expansion

Despite the emerging concerns, reports indicate that CMS might be considering expanding the WISeR model to include a broader range of treatments, such as oncology and cardiac care [Medicare Rights Center]. This potential expansion comes at a time when the program is already under scrutiny for its impact on patient access to care.