Medicare's new AI prior authorization model linked to care denials, delays

A new artificial intelligence (AI) model, designed to streamline prior authorizations for Original Medicare, has been linked to inappropriate denials and delays in care for some beneficiaries. The model, known as the Wasteful and Inappropriate Service Reduction (WISeR) Model, was launched by the Centers for Medicare & Medicaid Services (CMS) in January of this year [Medicare Rights Center].

What is the WISeR Model?

The WISeR Model introduces an AI-forward prior authorization system for a select number of services within Original Medicare. This initiative is currently active in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington [Medicare Rights Center]. The procedures under review include specific types of pain injections, spinal surgeries, and nerve treatments [Medicare Rights Center]. Historically, Original Medicare has used very little prior authorization compared to Medicare Advantage plans, which tend to have more barriers to accessing care [Medicare Rights Center].

Reports of Delays and Denials

Since its implementation, reports have emerged detailing that the WISeR model has increased the waiting times for beneficiaries needing procedures, forcing them through appeals processes following initial denials [Medicare Rights Center]. These issues have been highlighted in new records and previous reporting, which indicate that the AI model is leading to delayed care and significant burdens for both patients and providers [Medicare Rights Center]. There are also reports that CMS might intend to expand WISeR to include more types of treatments, such as oncology and cardiac care [Medicare Rights Center].

Concerns Over Program Design

One significant concern raised about the WISeR model's design is a potential bias toward denying care. 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 these AI decisions are meant to be reviewed by qualified human clinicians, studies suggest that clinicians can be influenced by an initial denial, potentially compromising the review process [Medicare Rights Center]. Advocates argue that even with an appeals process, these inappropriate denials can cause substantial harm, as many beneficiaries may not successfully navigate the appeals system.