A recent Medicare pilot program using artificial intelligence (AI) for reviewing prior authorization requests has resulted in significant treatment delays and concerns over inadequate testing. These insights come from newly released government records disclosed through a Freedom of Information Act (FOIA) lawsuit initiated by the Electronic Frontier Foundation (EFF). This lawsuit sought to reveal information about the federal government’s Wasteful and Inappropriate Service Reduction (WISeR) model. The WISeR model, launched in January, integrates AI-assisted reviews for certain medical procedures.
EFF is actively pursuing legal action against the Centers for Medicare & Medicaid Services (CMS) to compel the release of more records about AI’s role in Medicare. Michael Ryan, a finance expert, expressed concerns to Newsweek about the hasty introduction of AI in prior authorization processes without comprehensive testing, leading to administrative inefficiencies. Instead of speeding up procedures, AI is causing significant bottlenecks.
Program Details
The WISeR program represents one of the federal government’s attempts to incorporate AI into Medicare administration. Currently, the pilot is active in six states: Texas, Arizona, New Jersey, Ohio, Oklahoma, and Washington. It covers 13 medical services identified by CMS as prone to fraud or misuse. Providers must obtain authorizations through technological platforms managed by private contractors using AI tools for evaluations.
Operational Problems
Documents from the EFF lawsuit reveal widespread operational issues since WISeR’s inception. Delays in responding to authorization requests are common, with CMS initially stating a 72-hour response window. However, records show some requests unaddressed for up to 83 days. There have been inappropriate denials and instances of patient harm due to these delays. Kevin Thompson, CEO of 9i Capital Group, highlighted how these problems stem from insufficient testing of the systems before launch. The increased denials and longer authorization times reflect systemic issues.
“In the absence of rigorous safeguards, AI-driven prior authorization determinations can lead to unwarranted—and even discriminatory—delays or denials of necessary medical care,” EFF stated.
EFF pointed out the lack of transparency regarding the AI systems used by WISeR vendors. Although CMS mandates a human clinician review all denials, research suggests that AI recommendations can heavily influence human decisions.
Response from CMS
CMS has responded to concerns, stating its commitment to addressing the timeliness, accuracy, and transparency goals of the WISeR model. They plan to update the model in response to feedback from doctors and patients.
Earlier reports, including a June investigation by KFF Health News, revealed similar issues. Patients experienced prolonged waits, confusion, and additional travel needs after WISeR’s introduction of prior authorization rules. Medical organizations criticized the rollout, saying it placed undue administrative pressure on providers.
Thompson noted that delayed treatment is a significant concern, as longer approval times can prevent patients from receiving timely care. He anticipates CMS will continue expanding the WISeR model as a cost-saving measure, despite the current challenges.
Concerns Over Testing
EFF is particularly concerned about whether CMS adequately tested the technology prior to launching the program. Their FOIA request sought records on testing for accuracy, bias, and system functionality. EFF argues that transparency is essential since AI-based recommendations can unduly influence human reviewers’ decisions.
Ryan remarked that the lawsuit does not suggest Medicare will abandon AI. WISeR is scheduled to continue through 2031, and CMS views technology-assisted authorization as part of its strategy, despite the current issues. Nevertheless, expanding the program without ensuring faster, safer care would be misguided.
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