CMS’ AI program to add prior authorizations to traditional Medicare; new bill aims to stop it
A new AI model being piloted by the Centers for Medicare & Medicaid Services (CMS) promises to “protect American taxpayers” by combining machine-learning and “human clinical review” to automate traditional Medicare prior authorization claims in six states. However, a group of Democrats in the U.S. House of Representatives are seeking to halt the project, before it is officially rolled out on January 1, 2026.
Led by Rep. Susan DelBene (D-WA), the coalition has put forth a new bill to halt the “WISeR (Wasteful and Inappropriate Service Reduction) Model,” set to remain in effect through 2031 in New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington.
Effectively, what the AI will do is add the prior authorization process—typically used by privatized Medicare Advantage plans—into traditional Medicare, meaning that providers will need to get advanced reimbursement approval for certain procedures and tests.
However, the AI would, ideally, simplify much of the process, making decisions based on cost containment and clinical need automatically. CMS argues that the technology will reduce Medicare fraud. However, DelBene, et al. rebuke that, contending that the policy will simply move the chaos of delayed care, commonly associated with Medicare Advantage, to the traditional Part A and Part B plans.
"We know that prior authorization in Medicare Advantage and elsewhere ultimately limits access to care, increases the burden on loved ones and care providers, and leads to worse health outcomes,” DelBene said in an announcement. “The administration has publicly admitted that prior authorization is harmful, yet it is moving forward with this misguided effort that would make seniors navigate more red tape to get the care they’re entitled to.”
“Congress needs to step in and protect seniors, their families, and health care workers by stopping this model,” she added.
Ending fee-for-service
According to CMS, the WISeR model will only be used to halt “wasteful” and low-value services “shown to have little to no clinical, evidence-based benefit.” Technology companies have agreed to adopt the framework in the participating states, the agency said—effectively ending the fee-for-service system, where providers are reimbursed after patient care is delivered and tests are ordered.
Those adopting the WISeR framework are already using AI for medical claims. The list includes Cohere Health, Genzeon Corporation, Humata Health, Innovaccer, Virtix Health and Zyter.
CMS said they will be reimbursed based on any savings they make to the program—effectively incentivizing them to flag claims, which equates to denied care. This, to DelBene and the others supporting the “Seniors Deserve SMARTER (Streamlined Medical Approvals for Timely, Efficient Recovery) Care Act,” creates a perverse-incentive structure that mirrors Medicare Advantage.
“In recent years, the U.S. Department of Health and Human Services revealed that Medicare Advantage plans ultimately approved 75% of requests that were originally denied, and a 2022 HHS report further revealed that Medicare Advantage plans frequently violated Medicare coverage rules in their use of prior authorization,” the announcement from DelBene’s office reads. “Nearly a third of physicians report that prior authorization has led to a serious adverse health event for a patient in their care.”
The initial vendor list is also likely to expand as time goes on, since CMS has not limited the number of participants in this AI prior authorization experiment.
If passed, the Seniors Deserve SMARTER Care Act will terminate the entire project.
The Democrats supporting the bill include Reps. Greg Landsman (D-OH), Ami Bera, MD (D-CA), Kim Schrier, MD (D-WA), Mark Pocan (D-WI), and Rick Larsen (D-WA).
Chad is an award-winning writer and editor with over 15 years of experience working in media. He has a decade-long professional background in healthcare, working as a writer and in public relations.