Legislation Targets AI-Based Medicare Prior Authorization Pilot in Washington

U.S. Senators Patty Murray and Ron Wyden are introducing legislation to block a federal pilot program by the Centers for Medicare and Medicaid Services (CMS) that integrates artificial intelligence (AI) reviews into Medicare procedure approvals. This program, called Wasteful and Inappropriate Service Reduction (WISeR), aims to streamline prior authorization for certain procedures susceptible to waste and fraud, starting in 2026 in six states including Washington. The legislation addresses concerns from healthcare providers, patient advocates, and senior citizens about potential delays and denials in care due to AI involvement and the financial incentives for AI vendors to reduce approved services. CMS designed the WISeR model to reduce unnecessary and costly medical procedures like certain nerve stimulators, steroid injections, and spine surgeries, excluding emergency services and inpatient stays from review. While CMS assures providers retain final review authority over denials, physicians and hospital groups in pilot states have expressed apprehension about the administrative burden and interference with clinical decision-making. They argue that prior authorization already delays care and that adding AI layers may exacerbate these issues. Health practitioners in Washington State, including leaders from the Washington State Medical Association and hospital associations, emphasize concerns that AI-driven decisions may obstruct patient access to necessary treatments. Reports from the American Hospital Association and the U.S. Department of Health and Human Services highlight the prevalence of delayed or inappropriately denied Medicare Advantage care, highlighting systemic challenges within prior authorization processes. These insights fuel opposition to the pilot, especially from clinicians who warn that it hinders their ability to provide timely care. The pilot’s implementation raises questions about its future scope and impact on providers' workloads amid existing administrative challenges related to prior authorizations. Stakeholders like the Washington State Hospital Association are apprehensive about potential expansion of the program to additional procedures and the resulting operational strains. Advocates call for policy focus to shift towards reforming Medicare Advantage plans where data suggest more significant issues of waste and fraud. In summary, the WISeR pilot program faces critical scrutiny over AI application in Medicare claim reviews, with pending legislation seeking to prevent its rollout in Washington and other states. The debate centers on balancing fraud prevention and administrative efficiency against risks of care delays, provider burden, and patient access complications within traditional Medicare frameworks. The outcome of this legislative push will have implications for federal oversight and use of AI in Medicare prior authorizations.