Medicare AI Prior Authorization Model Linked to Inappropriate Care Denials

The introduction of an artificial intelligence (AI) powered prior authorization system within Medicare’s Original Medicare program, called the Wasteful and Inappropriate Service Reduction (WISeR) Model, has led to reports of inappropriate care denials and delays for beneficiaries [Medicare Rights Center]. This program, launched by the Centers for Medicare & Medicaid Services (CMS) in January of this year, is a six-year pilot initially operating in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington [Medicare Rights Center].

Historically, Original Medicare has been known for fewer barriers to accessing care compared to Medicare Advantage plans, which often employ more extensive prior authorization requirements [Medicare Rights Center]. However, the WISeR model aims to create a new prior authorization system for a select number of Original Medicare services.

Concerns Over Delays and Denials

Recent records and earlier reports indicate that the WISeR model has resulted in undue delays, outright denials of care, increased burdens for healthcare providers, and potential harm to older adults and other beneficiaries receiving Original Medicare [Medicare Rights Center]. For instance, beneficiaries have experienced longer waits for procedures as they navigate the often-complex processes of denials and appeals [Medicare Rights Center].

The procedures subjected to WISeR prior authorization are varied, including certain pain injections, spinal surgeries, and nerve treatments [Medicare Rights Center]. There are also reports suggesting that CMS may intend to expand the WISeR model to encompass a broader range of treatments, potentially including oncology and cardiac care services [Medicare Rights Center].

Flawed Program Design Raises Questions

A central concern with the WISeR model lies in its design, which some critics argue inherently biases toward denying care [Medicare Rights Center]. The AI companies responsible for making the initial coverage decisions are reportedly compensated more when they block access to medical services [Medicare Rights Center]. While human clinicians are tasked with reviewing these AI decisions, studies suggest that these clinicians can be influenced by an initial denial made by the AI [Medicare Rights Center].

This raises significant questions about the fairness and patient-centeredness of the program. The implications of such a system are particularly profound for individuals relying on Medicare for essential health services, highlighting the critical need for careful oversight and evaluation as AI tools become more integrated into healthcare decision-making.

Understanding Prior Authorization

Prior authorization is a process requiring healthcare providers to obtain approval from an insurance company before a patient can receive certain medical services, treatments, or medications. While often framed as a cost-saving measure to prevent unnecessary care, its implementation, particularly with AI, can introduce hurdles that impede timely access to medically necessary services. For Medicare beneficiaries, understanding how these systems work and their rights to appeal denials remains vital in navigating the evolving healthcare landscape [KFF Medicare]. CMS has previously expressed commitment to ensuring stability in Medicare Advantage and prescription drug programs for 2027, including significant premium savings, but the WISeR model specifically affects Original Medicare beneficiaries and highlights a different aspect of program management [CMS Newsroom].