CMS to pilot AI-based prior authorization for Medicare claims
The Centers for Medicare and Medicaid Services announced a pilot program using artificial intelligence to assess whether Medicare claims are appropriate before authorization, expanding a process previously limited to Medicare Advantage plans. Critics raise concerns that AI companies have financial incentives to deny claims and that the system could inappropriately restrict patient access to necessary medical care.
What happened
The Centers for Medicare and Medicaid Services (CMS) announced a pilot program called the Wasteful and Inappropriate Service Reduction (WISeR) Model, scheduled to begin in six states in 2026, using artificial intelligence algorithms to assess the appropriateness of certain medical services for Original Medicare recipients.
The AI program will apply prior authorization to Original Medicare recipients, a process previously common only for Medicare Advantage beneficiaries. According to reports, the AI algorithms will be used to determine whether care recipients are receiving appropriate services and to reduce wasteful or inappropriate care.
Reported impact
Critics have warned that AI companies involved in prior authorization have financial incentives to deny claims, and similar AI-based algorithms have faced litigation.
The program has been described as potentially problematic for patient care, with concerns that AI systems could deny necessary medical services.
Index analysis
The CMS program represents an expansion of prior authorization requirements to Original Medicare, which has traditionally not required such approval processes, potentially changing access to care for millions of beneficiaries.
Governance controls
The CMS program is described as a pilot test aimed at improving and expediting prior authorization processes while safeguarding federal taxpayer dollars. The extent of oversight mechanisms or appeals processes for AI-based denials is not detailed in the available sources.
Classification
Sources and evidence
This record was researched and written by the Index, based on the following original reporting.