Sept. 5, 2025
Medicare Launching AI Prior Authorization Pilot Program
Washington state is among six states included in a prior authorization pilot program that begins on Jan. 1, 2026 for enrollees of traditional Medicare. Titled the Wasteful and Inappropriate Service Reduction (WISeR) Model by the Centers for Medicare & Medicaid Services, the program will apply prior authorization requirements to selected services, with artificial intelligence slated to play a role in utilization management.
The WSMA has numerous, significant concerns with the program. It represents a shift in the Medicare program's approach to utilization management, applies more administrative burden to physicians, potentially utilizes AI technology that may not be fully vetted, and runs counter to multiple current efforts to reform and pare back prior auth. And of course, most importantly it may create barriers to patients being able to get needed care in a timely fashion.
For patients, delays in accessing care can be dangerous. In a 2024 American Medical Association survey, nine out of 10 physicians reported that prior authorizations delay access to needed care; 29% said their patient suffered a serious adverse event because treatment was stalled. The same survey found that physicians are already spending nearly two full workdays each week dealing with prior authorization.
Criticism of the WISeR program is mounting. Last month the AMA sent a letter to CMS outlining concerns and urging CMS to delay implementation of the program. Three members of Washington state's congressional delegation signed onto a letter to CMS raising concerns and asking specific questions about the program.
We know that the best person to make care treatment decisions about a patient is the person in the room examining them, listening to them, laying hands on them, discussing their situation, and who has the clinical experience to evaluate and treat the patient for whatever they are facing. Not AI, and certainly not an insurance company that is looking for any excuse to bring the cost of the bill down.
The WSMA will engage in conversations around the WISeR program and will keep members apprised of future developments. In the meantime, more details on the program are available at this CMS webpage and a list of proposed services that will be included is available at page 20 of the program RFA.