AI Will Decide Medicare Approvals

The Trump administration is taking a cue from the private insurance industry playbook to launch a pilot program next year, aimed at determining how much money the federal government could save by using an artificial intelligence (AI) algorithm to deny care to Medicare patients.

This pilot program, named WISeR (Wasteful and Inappropriate Service Reduction), represents a federal expansion of "prior authorization," a generally unpopular process that requires insurance approval before specific procedures, tests, or prescriptions. WISeR is designed to weed out wasteful or "low-value" services and will initially focus on procedures the government considers vulnerable to "fraud, waste, and abuse," such as electrical nerve stimulator implants and knee arthroscopy.

The pilot will start on January 1 and run through 2031, affecting Medicare patients and providers in six states: Arizona, Ohio, Oklahoma, New Jersey, Texas, and Washington. Historically, traditional Medicare (which covers adults 65 and older and some people with disabilities) has mostly eschewed prior authorization.

The initiative has raised suspicions among experts and politicians, especially due to its surprising late-June announcement. This occurred only days after the administrator of the Centers for Medicare & Medicaid Services (CMS), Mehmet Oz, unveiled a voluntary effort for private insurers to reduce prior authorization, which "erodes public trust" and causes care to be "significantly delayed".

Critics like Dr. Vinay Rathi, a policy researcher, and Representative Suzan DelBene, have accused the administration of sending "mixed messages" or of "talking out of both sides of their mouth". Patients and doctors view prior authorization as a "delay-or-deny" tactic that can cause "irreparable harm and even death". A KFF poll in July found that nearly three-quarters of the public consider prior authorization a "major" problem.

Although experts agree that AI could theoretically expedite the cumbersome prior authorization process, there are serious doubts about its implementation. Policy researchers believe that private insurers' algorithms are often programmed to automatically deny high-cost care. Jennifer Oliva, a law professor, noted that the more expensive a service is, the more likely it is to be denied, and that insurers are motivated to rely on the algorithm if a patient is expected to die within a few years.

The Medicare pilot promises safeguards. Alexx Pons, CMS spokesperson, assured that no Medicare request will be denied without review by a "qualified human clinician", and that vendors are prohibited from receiving compensation arrangements tied to denial rates. However, Jennifer Brackeen, director of government affairs, warns that "shared savings arrangements" financially benefit vendors when less care is delivered, creating a powerful incentive to deny medically necessary care.

Doctors and lawmakers are concerned that the AI algorithm could overreach into the practice of medicine by denying doctor-recommended care. Bipartisan members of the House of Representatives even supported a measure to block funding for the WISeR pilot in the fiscal 2026 budget.

Representative Greg Murphy, while open to seeing the results of the pilot, concluded: "I will always, always err on the side that doctors know what’s best for their patients".

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AI Will Soon Have a Say in Approving or Denying Medicare Treatments

Private health insurers use AI to approve or deny care. Soon Medicare will, too

AI will soon have a say in approving or denying Medicare treatments

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