The federal government is set to launch a six-year pilot program in Washington and five other states that will use artificial intelligence to review certain medical procedures for Medicare patients. The initiative, which begins January 1, aims to reduce unnecessary spending but has drawn criticism from physicians and lawmakers over concerns about patient care and potential privatization.
Key Takeaways
- A new Medicare pilot program, named WISeR, will use AI for prior authorization in six states, including Washington, starting January 1.
- The program applies to traditional Medicare and covers specific outpatient procedures deemed to have questionable clinical value relative to their cost.
- Participation is voluntary for doctors, but critics worry it introduces new barriers to care and creates a financial incentive for third-party companies to deny procedures.
- Lawmakers and medical associations have expressed strong opposition, citing a lack of transparency and the potential for automated systems to override clinical judgment.
New AI-Powered Review System for Medicare
The U.S. Centers for Medicare and Medicaid Services (CMS) will begin a new program called Wasteful and Inappropriate Services Reduction (WISeR) in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. This six-year test will apply to enrollees in the traditional Medicare program, which has historically required less pre-approval for services compared to private Medicare Advantage plans.
The stated goal of the program is to address fraud, waste, and abuse within the Medicare system. According to CMS, the initiative will focus on a specific list of outpatient procedures that officials believe are sometimes provided without sufficient medical benefit to justify their cost.
Third-party companies will use artificial intelligence algorithms to assess whether these procedures are eligible for coverage. However, a key safeguard requires that any denial of care recommended by the AI must be reviewed by a human healthcare professional before a final decision is made.
Program at a Glance
- Name: Wasteful and Inappropriate Services Reduction (WISeR)
- Duration: 6-year pilot program
- Start Date: January 1, 2026
- States: Washington, Arizona, New Jersey, Ohio, Oklahoma, Texas
- Technology: Artificial Intelligence for prior authorization
Concerns from Medical Professionals and Lawmakers
The introduction of AI into Medicare decisions has been met with significant resistance. Medical groups argue that it places an automated system between doctors and their patients, potentially disrupting established care plans.
"Patients expect their care to be guided by doctors, not insurance companies or automated systems," said Dr. Matt Hollon of the Washington State Medical Association.
A major point of contention is the payment model for the third-party companies managing the AI reviews. These firms will be compensated with a portion of the money saved from denied procedures, creating what critics call a direct financial incentive to refuse care.
Dr. Hollon added that this model is "antithetical to health care," as AI systems analyzing aggregated data may not account for the unique circumstances of an individual patient. CMS has stated that companies will face penalties for wrongful denials and delays in processing requests.
Political Opposition and Calls for Transparency
The program has also drawn sharp criticism from elected officials. Washington Senator Patty Murray described the initiative as a "backdoor move by Republicans to privatize Medicare and let AI decide who deserves health care." She has pledged to oppose the program in the Senate.
In the House of Representatives, U.S. Rep. Suzan DelBene led a group of lawmakers in sending a letter to CMS Administrator Mehmet Oz seeking more information about the program's design and objectives. As of late September, the group had not received a response, fueling concerns about a lack of transparency in the rollout.
The Broader Debate on Prior Authorization
Prior authorization, the process of getting pre-approval from an insurer before a procedure, is a common practice in private health insurance and Medicare Advantage plans. It is often cited by doctors as a major administrative burden that can delay necessary care. Traditional Medicare has used it far less frequently, making the WISeR program a significant shift in policy.
How the WISeR Program Will Function
Under the pilot, participation for physicians is voluntary. Doctors can choose to submit prior authorization requests through the new system. The incentive for doing so is to receive confirmation of payment before a procedure is performed, avoiding the risk of a claim being denied after the fact.
If a doctor chooses not to participate, their claims for the targeted procedures will undergo a traditional pre-payment review process. However, some policy experts, like Jeb Shepard of the Washington State Medical Association, view this voluntary phase as a "first foray" that could become mandatory in the future.
Targeted Medical Procedures
The list of services subject to review includes those with rapidly increasing costs and debated clinical effectiveness. Examples include:
- Expensive skin and tissue substitutes
- Deep brain stimulation
- Cervical fusion
- Knee arthroscopy for osteoarthritis
- Certain treatments for impotence
A CMS spokesperson clarified that the objective is to "help patients avoid unnecessary, inappropriate procedures across a narrow set of services."
Mixed Reactions and an Uncertain Future
While opposition is widespread, not all assessments of the WISeR program are negative. Tim Smolen, a program manager at Washington’s Office of the Insurance Commissioner, suggested it could be a "net positive" if it works as intended. He noted that a faster and more definitive answer on coverage could reduce financial surprises for both patients and medical providers.
Patient advocacy groups are monitoring the situation closely. An AARP spokesperson acknowledged the need to address Medicare fraud but emphasized that "the health care of older Americans must always come first, and nobody should be denied legitimate treatments they need."
The debate over the role of AI and prior authorization is also active at the state and federal levels. Washington state lawmakers are expected to reconsider legislation in 2026 to increase oversight of these practices. At the same time, a bipartisan federal bill pushed by Rep. DelBene aims to streamline the existing prior authorization process in Medicare Advantage plans, highlighting the broad-based concern over these administrative systems in healthcare.
