artificial intelligence

The federal government’s pilot program testing artificial intelligence-driven prior authorization in Medicare, known as the Wasteful and Inappropriate Service Reduction Model (WISeR), has triggered significant patient and provider backlash in six states. According to reports from KFF Health News, the program, launched in January 2025, requires preapproval for 13 specific medical services, leading to reports of long wait times, administrative errors, and stalled care for beneficiaries in Oklahoma, Arizona, New Jersey, Ohio, Texas, and Washington.

Why is Medicare using AI for prior authorization?

Federal officials, including Centers for Medicare & Medicaid Services (CMS) leader Mehmet Oz, state the program aims to curb fraud and misuse in specific, high-cost services. According to Department of Health and Human Services (HHS) inspector general data from September 2024, spending on skin substitutes surged nearly 700% over two years, prompting concerns about waste. Through the WISeR model, CMS uses AI-powered portals to review clinical data. Humata Health CEO Jeremy Friese stated that the system provides an “immediate yes” in 88% of cases where clinical documentation supports the request. The goal, according to Abe Sutton of the Center for Medicare and Medicaid Innovation, is to ensure the process remains “efficient, fast, and streamlined.”

What are the primary challenges for patients and doctors?

Early implementation in the six pilot states has been characterized by confusion and delays. According to a report from the office of U.S. Sen. Maria Cantwell (D-Wash.), the University of Washington’s medical system faced a backlog of nearly 100 patients awaiting epidural injections earlier this year due to WISeR-related complications. Physicians, such as New Jersey-based doctor Dorota Gribbin, report that authorization delays often force patients to seek more expensive emergency care. Furthermore, clinicians have reported instances of “nitpicking” by reviewers and requests for imaging that is already present in patient files, according to Jennifer Valle of Clinical Radiology of Oklahoma.

How does the WISeR model impact healthcare costs?

While the program is intended to save money, it is simultaneously increasing administrative expenses for the federal government. Medicare’s Abe Sutton acknowledged that the agency has accounted for potential increases in the volume of appeals filed by providers, which are handled by government contractors. Miranda Yaver, a health policy researcher at the University of Pittsburgh, suggests that prior authorization functions by shifting costs to patients and doctors through the “price” of wait times and inconvenience. There is a marked contrast between the government’s push for WISeR in Medicare and the current administration’s stated efforts to scale back prior authorization requirements within the private insurance market.

Pro Tip: Managing Prior Authorization Requests

If you are a provider participating in the pilot, ensure your clinical documentation explicitly addresses the specific criteria listed in the WISeR portal. Several physicians, including James Webb in Tulsa, have noted that even when documentation is provided, delays of six to eight weeks have occurred, making early submission and frequent follow-ups essential.

FAQ: Understanding Medicare’s New Pilot Program

• Which states are participating in the WISeR pilot? The program is currently active in Oklahoma, Arizona, New Jersey, Ohio, Texas, and Washington.
• Is AI making the final decision on my care? CMS vendors state that humans make final approval decisions, though clinicians report concerns that AI errors or “hallucinations” may be contributing to denials.
• Will this program expand to other procedures? CMS official Abe Sutton stated there are “currently no changes” considered for the list of 13 services, but the agency continues to assess the model’s performance.

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