The Centers for Medicare and Medicaid Services is set to launch a new pilot program that uses artificial intelligence to review medical claims for older Americans. While intended to reduce wasteful spending, the initiative has triggered significant concern among physicians who fear it could create new barriers to essential healthcare for a vulnerable population.
The program, known as the Wasteful and Inappropriate Services Reduction (WISeR) Model, will begin next month in six states and is scheduled to run through 2031. It involves private companies using AI algorithms to conduct prior authorizations, with a financial model that rewards them for denying care, a detail that has drawn sharp criticism from medical professionals and lawmakers.
Key Takeaways
- Medicare is launching the WISeR Model, a pilot program using AI to review medical service requests.
- The program will operate in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington until 2031.
- Private companies running the AI reviews are financially rewarded for denying claims.
- Physicians and medical associations are concerned the program will delay or prevent necessary care for seniors.
- A bipartisan bill has been introduced in Congress to repeal the WISeR program before it starts.
A New Approach to Medicare Claims
The federal government is testing a new strategy to manage healthcare costs within its Medicare program. The WISeR Model is designed to identify and prevent payments for medical services deemed unnecessary or inappropriate. This initiative delegates the review process to private contractors who will employ AI systems to analyze requests for certain types of medical care before they are approved.
This marks a significant shift, introducing an automated layer of scrutiny that has not previously been standard for many Medicare recipients. The stated goal is to enhance efficiency and curb unnecessary expenditures in the national healthcare system. However, the methodology and its potential consequences are now under intense debate.
What is Prior Authorization?
Prior authorization, also known as pre-authorization or pre-certification, is a process used by health insurance companies to determine if they will cover a prescribed procedure, service, or medication. It requires physicians to obtain approval from the insurer before providing care to a patient, a process that can often lead to delays and administrative burdens.
Physician Concerns Mount Over Patient Access
Medical professionals in the participating states are raising alarms about the potential impact on patient care. The primary concern is that an automated system, especially one with an incentive to deny services, could wrongly reject legitimate and necessary medical treatments. This could force elderly patients into lengthy and complicated appeals processes to get the care they need.
Jeb Shepard, the policy director for the Washington State Medical Association, acknowledged the logic behind avoiding wasteful spending but highlighted the practical issues with prior authorization systems.
"In concept, it makes a lot of sense; you don’t want to pay for care that patients don’t need. But in practice, [prior authorization] has been hugely problematic because it essentially acts as a barrier. There are a lot of denials and lengthy appeals processes that pull physicians away from providing care to patients."
Doctors argue that these administrative battles take them away from their primary duty: treating patients. The introduction of an AI gatekeeper is seen by many as an escalation of this problem, potentially creating a less transparent and more rigid system for patients to navigate.
WISeR Program at a Glance
- Launch: Next month
- Duration: Through 2031
- Participating States: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington.
- Technology: Artificial Intelligence (AI) for medical claim reviews.
The Financial Incentive to Deny Care
A central point of contention is the program's financial structure. The private companies tasked with administering the AI reviews are rewarded when they deny care. This creates what critics call a perverse incentive, where profitability is directly linked to withholding medical services. This model raises questions about whether decisions will be based purely on medical necessity or influenced by financial targets.
Dr. Bindu Nayak, a physician, emphasized the vulnerability of the population affected by this change.
"Medicare recipients are a vulnerable group. The WISeR program puts more barriers up for them accessing care. And they may have to now deal with prior authorization when they never had to deal with it before."
For many seniors on Medicare, navigating the healthcare system is already a challenge. The addition of an AI-driven prior authorization process managed by a company with a financial stake in claim denials is viewed by many as an unacceptable risk to their health and well-being.
Legislative Pushback and the Future of WISeR
The concerns have not gone unnoticed on Capitol Hill. In response to the growing criticism from the medical community, a bipartisan group of congressional representatives introduced legislation last month to repeal the WISeR model entirely. The bill, led by lawmakers from some of the states affected by the pilot program, aims to halt the initiative before it can be implemented.
The legislation is currently in committee, and its future is uncertain. However, its introduction signals a significant level of political opposition to the AI experiment. The debate highlights a fundamental tension in modern healthcare: the drive to use technology to control costs versus the need to ensure that patients, especially the elderly and vulnerable, receive timely and appropriate medical care.
As the launch date for the WISeR program approaches, patients, doctors, and lawmakers will be watching closely to see how these automated systems perform and whether the fears of increased barriers to care materialize.
