A new Medicare program that uses AI for prior authorizations is hurting patients and delaying care

By Jessica Hall

Six states are part of a pilot program by CMS to reduce 'waste, fraud and abuse'

Washington state healthcare providers report they are waiting 15 to 20 days for prior authorization answers, rather than the previous 24 to 72 hours.

A pilot program for Medicare that uses AI for prior authorizations has some patients waiting weeks longer to get medical procedures - if they receive care at all - and has providers facing costly new billing practices, according to a new analysis.

Under the new program that started in January, about 6.4 million Americans enrolled in traditional Medicare in New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington state face prior authorizations conducted by AI.

In Washington state, patients are waiting up to three weeks rather than days to find out whether they can get care - and then waiting two to four times longer than normal for a medical procedure to be completed, U.S. Sen. Maria Cantwell, a Washington Democrat, said in a report.

The program - known as the Wasteful and Inappropriate Service Reduction (WISeR) model - requires additional approvals for more than a dozen medical procedures, such as epidural steroid injections for pain management, minimally invasive treatments for spinal stenosis in the back and osteoarthritis in the knees, and nerve-stimulation therapies for conditions such as sleep apnea and incontinence.

Prior authorization means getting approval before an insurer will pay for a medical service or drug. Traditional Medicare currently has fewer prior-authorization requirements than Medicare Advantage, which is the private-plan alternative to Medicare. Fewer prior authorizations and a smoother pathway to care were reasons consumers preferred traditional Medicare.

On Wednesday, in response to Cantwell's comments about WISeR delays during a Senate Finance Committee hearing, U.S. Health and Human Services Secretary Robert F. Kennedy, Jr. said there were "probably kinks in the system" and pledged to work to "straighten it out."

The Centers for Medicare and Medicaid had "committed to responding to claims within 72 hours, but Washington providers report they are waiting 15 to 20 days for determinations, which are most often denials issued without any clear justification," Cantwell said in a letter on Thursday to Kennedy.

"Procedures that were typically completed within two weeks prior to WISeR now take four to eight weeks. That frequently forces patients to reschedule care multiple times, prolonging pain and allowing underlying conditions to worsen," Cantwell said in the letter.

Cantwell urged Kennedy to require contractors administering WISeR to respond to standard claims within 72 hours and urgent claims within 24 hours. Also, any denial issued should include a written explanation from a human reviewer, not AI, she said.

Cantwell also urged CMS to prohibit contractors from denying care when a patient's medical team has documented that reasonable alternatives have been considered and ruled out.

The WISeR program is part of the Trump administration's efforts to cut what it calls waste, fraud and abuse in government. The companies contracting to do the review process receive payments when they reduce costs, which critics have said essentially incentivizes them to deny service.

"This model incentivizes WISeR contractors to weaponize AI-driven medical determinations not for the sake of efficiency, as it could be used, but for the opportunity to maximize profitability," Cantwell said in the report.

CMS should publicly report the number of denials issued through WISeR and the financial gains realized by contractors administering the program, Cantwell said. Also, before expanding the WISeR program, CMS should provide Congress with a written analysis of the results of the pilot program.

"Early implementation comes with operational adjustments. CMS is closely monitoring performance and will take corrective action if any part of the model creates inappropriate barriers to access," Abe Sutton, CMS Innovation Center director, said in an emailed statement to MarketWatch.

"CMS does not have evidence of inappropriate denials currently," a CMS spokesperson added.

Cassie Sauer, chief executive officer of the Washington State Hospital Association, said that the WISeR vendor in that state, Virtix Health, appears "particularly aggressive and unresponsive." That's leading patients to linger in pain as conditions worsen - increasing the use of pain medication to manage the longer wait times.

Vitrix Health did not immediately respond to a request for comment.

"There's a lot of worry that people will or are turning to less safe forms of pain control," Sauer said. "We have a national goal not to have people take opioids, and the fact that we have a program in place that is encouraging that to happen is reprehensible."

In addition to patients waiting longer for procedures, Washington doctors and hospitals are spending more time appealing claims. Washington medical providers have been forced to add staff and increase hours dedicated to the prior authorization processes. These additional burdens prompted by the WISeR model are creating new costs in Washington state's healthcare system, driving up the cost of care, Cantwell said.

"There are so many delays. Having Vitrix even follow the rules of the program would be helpful," Sauer said.

-Jessica Hall

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04-27-26 1226ET