6 states join pilot AI Medicare program
AARP, doctors among those voicing concerns
By: Jeff Elkins
The Oklahoman
USA Today Network
OKLAHOMA CITY - New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington are the six states set to participate in a federal pilot program using artificial intelligence for Medicare claims that's already raising concerns about how automation will affect prior-authorization decisions.
.....
The program, slated to begin in January 2026 and end December 31, 2031, is called the Wasteful and Inappropriate Service Reduction Model.
..... Created by the Center for Medicare & Medicaid services, the WISeR Model marks a change in the agency's approach to prior authorization and prepayment reviews for original Medicare, which includes Medicare Part A, hospital insurance, and Medicare Part B, medical insurance.
..... Waste in helaht care, contributes to up to 25% of industry spending, according to the website for the agency, which provides health coverage to more than 160 million through Medicaid, Medicare, the Children's Health Insurance Program and the Heath Insurance Marketplace.
.....
The agency states the model is designed to reduce clinically unsupported care by working with companies experienced in using enhanced technology to expedite and improve the review process for select service vulnerable to fraud, waste and abuse.
..... AARP is among the organizations that will be closely watching the implementation of the pilot program.
..... An AARP spokespersons said the organization is "deeply concerned" about persistent reports of fraud and abuse of Medicare that are draining the system of much-needed resources but that the care of older Americans must come first, and no one should be denied treatments they need.
.....
CMS states the voluntary model will "streamline the review of medical necessity" earlier in the claim process tor educe inappropriate utilization, lower spending in original Medicare, expedite decision-making and ease provider administrative burden.
..... Dr. Sumit Nanda, president of the Oklahoma State Medical Association, said prior authorization has been used in the past as a way for Medicare HMOs to deny or delay care for patients. with an algorithm now involved in original Original Medicare, he said physicians are skeptical that patients will benefit from the pilot program, and many might be denied access to care they desperately need.
..... Physicians are increasingly speaking out about AI's role in health care. According to a 2024 poll form the American Medical Association, 61% of physicians said they feared insurers' use of unregulated AI is increasing prior-authorization denials.
..... Judy Stein, founder and senior adviser of the Center for Medicare Advocacy, said adding prior authorizations to traditional Medicare will cerate barriers to necessary care.
..... "Instead, to truly address waste and abuse in Medicare, CMS should look to the dramatic overpayment and unreasonable denials in Medicare Advantage," Stein said.