A Medicare pilot program will use artificial intelligence for prior authorizations. Doctors and lawmakers are alarmed.

Some prior authorization requests are already decided
by artificial intelligence. (Adobe Stock photo) 

A Medicare pilot program that allows private companies to use artificial intelligence to approve or deny medical care requested by their members has some doctors and lawmakers worried. Companies included in the pilot would get paid, "based on how much money they save Medicare by denying approvals," reports Anna Claire Vollers of Stateline.

The pilot, known as the Wasteful and Inappropriate Services Reduction (WISeR) Model, will launch after Jan. 1 in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington. WISeR is more likely to impact health care treatments for rural Americans in those states because rural populations often skew older and sicker than their suburban and urban counterparts.

At its core, the WISeR model effectively introduces a prior authorization process into traditional Medicare. Prior authorization is already unpopular with many patients and doctors because it requires members or medical providers to request an insurance company's approval for certain treatments or medications before proceeding.

While some Medicare Advantage and private insurance companies have already deployed AI into some of their prior authorization processes, its use has "attracted intense criticism, legislative action by state and federal lawmakers, federal investigations and class-action lawsuits," Vollers explains. "It’s been linked to bad health outcomes. Dozens of states have passed legislation in recent years to regulate the practice."

The new program has "alarmed many physicians and advocates in the affected states," Vollers reports. In practice, the prior authorization process can create obstacles to care by requiring physicians to spend hours fighting with an insurance company to justify the care they believe their patient needs. At times, medical providers may avoid treatments that would be best because an insurance company is likely to deny them, at least initially.

Last month, congressional representatives from several states "introduced a bill to repeal the WISeR model. It’s currently in committee," Vollers reports. The program is scheduled to run from 2026 to 2031.