Senators Seek to Block AI-Driven Medicare Prior Authorization Pilot

U.S. Senators Patty Murray and Ron Wyden have introduced legislation aimed at halting a Centers for Medicare and Medicaid Services (CMS) pilot program that integrates artificial intelligence (AI) into Medicare prior authorization reviews. This pilot, named Wasteful and Inappropriate Service Reduction (WISeR), is set to begin in 2026 across six states, including Washington, and seeks to streamline medical necessity determinations for selected procedures prone to fraud and abuse. The CMS asserts that the model intends to protect patients from unnecessary and costly treatments by partnering with third-party tech firms to conduct AI-driven reviews on specific services such as nerve stimulators, steroid injections, and spine surgeries, while excluding emergency and inpatient services from review. The proposed legislation aims to prevent the rollout of WISeR, citing concerns from healthcare professionals, patient advocacy groups, and Medicare enrollees about potential increases in care delays and denials under AI-based authorizations. Critics emphasize the risk of financial incentives for AI companies to deny care and the increased administrative burdens on providers who already face challenges with prior authorization processes. Data indicates that prior authorization delays are common in Medicare Advantage patients, leading to worsened health outcomes and inappropriate denials of authorized care. Washington state's healthcare community expresses particular concern due to its selection as a pilot site. Physicians, hospital leaders, and senior advocacy organizations argue that the program could disrupt the trusted patient-provider relationship inherent in traditional Medicare, and question why the state was chosen without transparent criteria. The Washington State Medical Association and hospital representatives have highlighted the risk of expanding prior authorization barriers, which they say obstruct timely medical care and increase workload demands. The pilot’s six-year timeline and potential future expansion remain points of contention among stakeholders, who urge caution regarding the integration of AI in clinical decision-making and urge policymakers to focus reform efforts on Medicare Advantage plans, where evidence points to significant overpayments and systemic inefficiencies. Providers also raise ethical concerns related to denials conflicting with physician medical judgment and advocate for transparency and accountability in AI application within Medicare prior authorization processes. Overall, the debate surrounding the WISeR program encapsulates broader tensions between innovation in healthcare administration and safeguards necessary to ensure patient access and provider autonomy. As CMS prepares to implement this AI-driven pilot, ongoing dialogue among lawmakers, clinicians, and community advocates continues to shape the regulatory environment around Medicare prior authorization reforms.