Early hospital data highlighted on Capitol Hill suggest that Medicare patients are waiting substantially longer to receive care due to a federal test program exploring automated evaluation of prior authorization claims in traditional Medicare.
The Wasteful and Inappropriate Service Reduction (“WISeR”) Model is a one-year, six-state pilot unveiled by the Centers for Medicare & Medicaid Services’ (CMS’) Innovation Center (CMMI) last summer and launched Jan. 1.
In line with the Trump administration’s push to weed out fraud, waste and abuse in Medicare, WISeR aims to use artificial intelligence to expedite prior authorizations for 13 medical services considered “low-value” or “vulnerable” to misuse, including skin and tissue substitutes. Beyond its technological components, the model is also a ramp-up of prior authorization in traditional Medicare, where it has so far not been widely used.
The approach—which has raised red flags among provider groups, nonprofits and some lawmakers—has received an initial poor review among Washington hospitals, per a report released this week by Senator Maria Cantwell (D-Wash.) based on data from 16 hospitals affiliated with the Washington State Hospital Association.
Topline, the report (PDF) flagged procedure completion times twice to four times as long as patients experienced prior to the model’s implementation “due to authorization delays.” For instance, procedures that were previously approved at the hospitals within “approximately” two weeks required four to eight weeks post-WISeR, according to the report, with patients “often rescheduled multiple times while awaiting authorization, causing prolonged pain and worsening underlying conditions.”
One organization highlighted in the report, the University of Washington Medical System, saw average approval times for its Urgent Authorizations (previously a single-day turnaround) and Standard Authorizations (previously three days) stretch to between 15-20 days after WISeR implementation. It also said it had nearly 100 patients waiting for one of the included procedures, epidural steroid pain injections, as a result of the model’s delays.
More than 18,600 Washington state residents received care services in 2024 through traditional Medicare that are now subject to prior authorization under the WISeR Model, according to the report.
Cantwell, who serves on the Senate Finance Committee, raised the findings Wednesday during a budgetary hearing with Health and Human Services Secretary Robert F. Kennedy Jr. She told him the treatment delays communicated by her constituents suggest that “AI is being used as a denial device for the CMS.”
“We have hospitals calling me about this, I have doctors calling me about this, I have patients calling me about this,” she told the secretary. “… To use AI as an app or a tool that might deny people and then cut them off from Medicare, when this part of Medicare was never a referral, is making me anxious that somebody really does think that AI should be used to judge our Medicare services.”
Kennedy said the delays described in the report are “unacceptable” and that his teams would work on ironing out what are “probably kinks in the system.” He defended the approach more broadly, saying that CMS was “being ripped off” on claims for the services selected in the pilot.
Cantwell, during Wednesday’s hearing, also touched on transparency and outstanding questions on how the AI tools used in the model are making their decisions. Kennedy responded that the program is “supposed to have a human supervisor” signing off on any claims identified for denial by AI.
Other issues flagged in the report were concerns among hospitals of increased administrative burdens and conflicts of interest due to the model’s structure, which has third-party administrators receiving a portion of the dollar value of any denied claims that aren’t later overturned. Such a structure could incentivize contractors to “weaponize AI-driven medical determinations … for the opportunity to maximize profitability.”
“Our patients are our top priority, and we are concerned that adding for-profit technology company layers between clinicians and care decisions can unintentionally create barriers for the people the system is meant to serve,” Tammy Buyok, president of MultiCare-owned Yakima Memorial Hospital, said in a quote included in the report.
The potential for extended delays, misaligned incentives and increased busywork were all among provider organizations’ chief rebuttals last year when weighing in on CMS’ plan to roll out the WISeR Model.
The American Hospital Association, for instance, pointed to “difficulties that our members have had with improperly administered prior authorization programs” outside of traditional Medicare and pushed for a delayed or more gradual rollout period. The American Medical Association, last year in member advocacy messaging, said it was “especially concerned that this model could further expand prior authorization requirements into Traditional Medicare, by setting a precedent for mandatory programs in the future.”
Washington State Hospital Association President and CEO Cassie Sauer, in a new statement, applauded Cantwell for bringing her members’ experiences to Kennedy’s attention and said the group “strongly opposes the use of [AI] in Medicare when it interferes with patient care.”
CMS’ exploratory expansion of prior authorization in traditional Medicare comes as the practice faces widespread pushback from the public and, by extension, lawmakers. A KFF poll in January found 32% of patients considered prior authorization a “major burden” when navigating their care, beating out understanding of their medical bills (23%) and scheduling appointments (20%).
Prior authorizations’ poor reputation led the industry’s major insurers to pledge rollbacks on their use of the practice—though revenue cycle data and earnings commentary from provider organizations suggest that denials are still having an impact.
