Happy 2026: AI Will Now Review Your Medicare

Pilot Program Will Require Prior Authorization for Selected Procedures

By Martin Burns

Beginning on January 1, the Centers for Medicare & Medicaid Services (CMS) will launch the Wasteful and Inappropriate Services Reduction (WISeR) Model “to test AI-powered prior authorizations on certain health services for Medicare patients in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington. The program is scheduled to last through 2031.”

While media attention about this pilot program has focused on the use of AI (artificial intelligence) to review medical health services, equally disturbing is that this pilot project interjects increased prior authorization more firmly into the Medicare program. In traditional Medicare, preauthorization is much less common than it is in Medicare Advantage. According to Forbes:

However, Medicare Advantage insurers use prior authorization extensively, subjecting hundreds if not thousands of procedures and technologies to the utilization restriction. By contrast, traditional Medicare uses prior authorization sparingly, for only 52 outpatient medical services, some durable medical equipment, and repetitive scheduled non-emergent ambulance transport.

AI is currently actively used in Medicare Advantage and private insurance with troubling results. The reaction to this approach has not been positive. Stateline reports that:

AI-powered prior authorization in Medicare Advantage and private insurance has attracted intense criticism, legislative action by state and federal lawmakers, federal investigations and class-action lawsuits. It’s been linked to bad health outcomes. Dozens.) of states have passed legislation in recent years to regulate the practice.

As a result of this criticism, this summer, several health insurers promised Health and Human Services Secretary Oz that they would reduce the number of claims subject to prior authorization review. Oz expressed confidence that Medicare Advantage and private insurers would make good on their commitments to use prior authorization more judiciously. The jury is still out as to whether these parties have performed up to Oz’s expectations.

One of the most concerning things about the AI Medicare prior authorization pilot program is that companies will be compensated based on the amount of money they “save” Medicare. So, to put the logic here quite simply: the more claims the companies reject, the more they make. This to my mind is a huge incentive for firms to deny Medicare beneficiaries access to their earned benefits.

In the House, representatives Suzan DelBene (WA-01), Greg Landsman (OH-01), Ami Bera, MD (CA-06), Kim Schrier, MD (WA-08), Mark Pocan (WI-02), and Rick Larsen (WA-02) introduced The Seniors Deserve SMARTER (Streamlined Medical Approvals for Timely, Efficient Recovery) Care Act that would repeal CMS’s WISeR project. Over in the Senate, a companion piece of legislation has been introduced by Senator Ron Wyden, (D-OR) ranking member of the Senate Finance Committee, Senator Patty Murray, (D-WA.), and Senator Kirsten Gillibrand, (D-N.Y), ranking member of the Senate Aging Committee.

I hope that some Republican members of Congress will co-sponsor The Seniors Deserve SMARTER Care Act and the appropriate congressional committees can begin hearings on this important piece of legislation. Given the current political dynamics on Capitol Hill, there is little chance this will happen. If the Republican leadership fails to act, I hope that Democrats will hold their own hearings to draw attention to this important issue.

Just days away from this misguided project, Axios reports that the American Medical Association is still unaware of how doctors can even submit a prior authorization request under WISeR. Certainly, it makes sense to try new things and it is essential that Congress and the Trump Administration make sure that every Medicare dollar is well-spent. However, the experience of prior authorization in Medicare Advantage clearly shows that the WISeR effort is not the smart way to address rising health care costs.