AI-Assisted Prior Authorization Pilot Launches in Washington Medicare

The federal government will launch a six-year pilot program starting January 1, 2026, in six states, including Washington, to implement an AI-assisted prior authorization process for certain medical procedures under traditional Medicare.

This new model, called Wasteful and Inappropriate Services Reduction (WISeR), aims to curb fraud, waste, and abuse by using third-party companies with AI technology to assess the necessity of select costly outpatient procedures. The program will initially be voluntary for doctors, who will submit prior authorization requests; those who do not participate will have their claims subjected to traditional pre-payment review. Washington state, with about 1.6 million Medicare beneficiaries split between traditional Medicare and Medicare Advantage, was chosen to represent a diverse practice environment. Procedures targeted include skin and tissue substitutes, impotence treatments, deep brain stimulation, cervical fusion, and knee arthroscopy for osteoarthritis, among others. Critics, including healthcare providers and lawmakers such as Senator Patty Murray, express concern over the use of AI to approve care, fearing it may not consider individual patient circumstances adequately and could incentivize improper denials because third-party companies share savings generated by the program. The Centers for Medicare and Medicaid Services (CMS) has stated that companies will face penalties for wrongful denials or delays and that healthcare professionals must review any AI denials. Medicare Advantage plans already employ prior authorization, often involving similar third-party reviewers, with most denials overturned upon appeal, but some patients remain unaware of their appeal rights.

Stakeholders such as the Washington State Medical Association acknowledge the burden prior authorization places on providers due to time constraints. Washington's Office of the Insurance Commissioner views WISeR's potential for faster coverage decisions as a possible benefit, reducing surprises for providers and beneficiaries. Congressional representatives, including Representative Suzan DelBene, have sought more information from CMS regarding pilot details and its impact, emphasizing the need for transparency and bipartisan oversight to ensure access to care.

At the state level, Washington lawmakers considered legislation to add oversight to prior authorization and define the role of AI, with renewed efforts expected in 2026. Meanwhile, federal efforts continue to push for accelerated prior authorization processes along with added safeguards for Medicare Advantage enrollees. Patient advocacy groups like AARP are monitoring the pilot closely, recognizing the balance between preventing Medicare abuse and safeguarding necessary patient treatments.