Legislation Targets AI-Driven Prior Authorization Pilot in Traditional Medicare

The Trump administration introduced the Wasteful and Inappropriate Service Reduction (WISeR) model, a pilot program set to begin in January 2026 in six states including Washington. This model will integrate prior authorization requirements into Traditional Medicare for the first time, using AI technology managed by private contractors to approve or deny certain medical procedures for seniors. The model creates new administrative burdens for healthcare providers and patients, particularly affecting small or low-resource practices. Third-party companies administering the AI decisions will be compensated based on the amount of reduced expenditures, creating incentives for denials of care. Despite CMS stating that human clinicians will review AI denials, official guidance and patient protections remain unclear as implementation approaches. The Seniors Deserve SMARTER Care Act has been introduced by Senators including Patty Murray, Ron Wyden, and Kirsten Gillibrand, aiming to prohibit the WISeR model due to concerns over care delays, increased red tape, and the privatization of Medicare benefits. The legislation is supported by multiple healthcare organizations and advocates who emphasize that clinical decisions should remain with healthcare providers rather than AI systems. Congressional Democrats have also called for detailed analysis and pause on the program's rollout, citing insufficient transparency regarding state selection, third-party contractor collaboration, and patient notification. Washington state is particularly impacted, with about 1.6 million Medicare enrollees, over half in Traditional Medicare. The legislation and advocacy highlight broader concerns about the shift towards automated care decisions and increased prior authorization requirements in public insurance programs. These changes propose significant challenges to provider workflow and patient access to timely medical care. The debate centers on balancing cost containment with safeguarding patient access and the integrity of Medicare clinical decision-making. The WISeR model pilot is planned to run for six years, potentially influencing future Medicare administrative processes and AI integration in healthcare authorization practices. The article underscores the ongoing legislative and healthcare community efforts to address the implications of AI implementation in Medicare prior authorization and maintain patient-centric care standards.