Early hospital data highlighted on Capitol Hill suggests Medicare patients are waiting much longer for care because of a federal trial program exploring automated prior authorization claims evaluation in traditional Medicare.
The Wasteful and Inappropriate Services Reduction (“WISeR”) model is a year-long pilot program in six states introduced by the Centers for Medicare & Medicaid Services (CMS) Center for Innovation (CMMI) last summer and launched on January 1.
In line with the Trump administration’s push to eliminate fraud, waste and abuse in Medicare, WISeR aims to use artificial intelligence to accelerate 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 an advancement of prior authorization in traditional Medicare, where it has not been widely used until now.
The approach, which has raised red flags among provider groups, nonprofits and some lawmakers, initially received a poor review among Washington hospitals, according to a report released this week by Sen. Maria Cantwell (D-Wash.) based on data from 16 hospitals affiliated with the Washington State Hospital Association.
top line, the report (PDF) noted procedure completion times two to four times longer than those experienced by patients before the model’s implementation “due to clearance delays.” For example, procedures that were previously approved by hospitals within “approximately” two weeks required four to eight weeks after WISeR, according to the report, and patients “were often rescheduled multiple times while waiting for clearance, 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) extended to between 15 and 20 days after implementing WISeR. He also said he had nearly 100 patients waiting for one of the included procedures, epidural steroid injections for pain, 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 budget hearing with Health and Human Services Secretary Robert F. Kennedy Jr. She told him that treatment delays reported by her constituents suggest that “AI is being used as a denial device for CMS.”
“We have hospitals that call me about this, I have doctors that call me about this, I have patients that call me about this,” he told the secretary. “…Using AI as an app or tool that could deny people and then exclude them from Medicare, when this part of Medicare was never a referral, makes me anxious that someone actually thinks 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 to fix what are “likely problems in the system.” He defended the approach more broadly, saying CMS was “being shortchanged” on claims for services selected in the pilot.
Cantwell, during Wednesday’s hearing, also addressed transparency and lingering questions about how the artificial intelligence tools used in the model are making their decisions. Kennedy responded that “the program is supposed to have a human supervisor” who signs off on any claims identified to be denied by AI.
Other issues noted in the report were concerns among hospitals about increased administrative burdens and conflicts of interest due to the model’s structure, in which third-party administrators receive a portion of the dollar value of any rejected claims that are not 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 layers of for-profit technology companies between physicians and care decisions could unintentionally create barriers for the people the system is intended to serve,” Tammy Buyok, president of MultiCare-owned Yakima Memorial Hospital, said in a quote included in the report.
The potential for long delays, misaligned incentives, and increased heavy lifting were among the top rebuttals from provider organizations last year when they evaluated CMS’s plan to implement the WISeR model.
He American Hospital AssociationFor example, it noted “difficulties our members have had with improperly administered prior authorization programs” outside of traditional Medicare and pushed for a delayed or more gradual implementation period. He American Medical AssociationIn a member advocacy message last year, he said he was “especially concerned that this model could further expand prior authorization requirements into traditional Medicare, 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’s exploratory expansion of prior authorization in traditional Medicare comes as the practice faces widespread public pushback and, By extension, legislators. A KFF survey conducted in January found that 32% of patients considered prior authorization a “major burden” in managing their care, surpassing understanding their medical bills (23%) and scheduling appointments (20%).
The poor reputation of prior authorizations led the industry’s major insurers to commit to reducing their use of the practice, although revenue cycle data and earnings feedback from provider organizations suggest that denials are still having an impact.
