The pilot program, called the WISeR Model, aims to help government officials decide whether patients are approved for certain medical procedures. AI will play a big part in making recommendations, but the Centers for Medicare and Medicaid Services said that a real person will always have the final say, and this initiative is part of broader commitment to create a patient-centric healthcare ecosystem.
The government hopes this AI approach will speed up the time-consuming process of prior authorization, particularly for outpatient treatments like skin and tissue substitutes, electrical nerve stimulator implants, and knee procedures. Traditionally, prior authorization in regular Medicare has been less common and usually faster than in other plans, but that could change with AI in the mix.
The decision to test this technology arrives alongside political pressure for Medicare to crack down on waste and fraud. The current administration is pushing to demonstrate that expense controls work, which is why AI is now getting a chance to drive more efficient decision making.
Questions about how this will affect patients have started piling up.
Kevin Thompson, CEO of 9i Capital Group, says, “For seniors, the impact could be substantial, especially when immediate care is critical.” He notes that more layers in the approval process could mean more delays and a higher chance of being turned down.
And it is not just delays that worry critics. Contractors who run the approval systems might be rewarded for keeping expenses down, so some fear AI could be used to justify denials, not just efficiencies. Recent Senate findings back this up, pointing to higher rates of care denials when algorithms are involved.
States Chosen for the Pilot
The new AI system will be tested in only a handful of states for now, with Arizona, Texas, Washington, New Jersey, Ohio, and Oklahoma set as the launch sites.
For anyone whose treatment falls under the scope of the program, the algorithms will not decide alone. Procedures that are particularly urgent or risky if delayed are excluded from the test, and inpatient services are not on the table.
Medicare Part B premiums are also on the rise, and this focus on efficiency is partly a response to projected increases, with rates expecting to jump by more than twenty dollars in the next year.
While the government frames this as a step into the future of public health, those affected remain wary.
Financial educator Alex Beene points out, “There’s justification for the red flags being raised.” He called the pilot notable and added that many are concerned about new obstacles cropping up in the road to care.
Medicare recipients are navigating an experiment that seeks swifter answers but could bring new worries and barriers along the way, much like other AI in health insurance decides your care and coverage.
