A Medicare pilot program that uses artificial intelligence to help review prior authorization requests has led to "lengthy treatment delays" in patient care and concerns about inadequate testing, according to newly released government records. The records, released as part of a Freedom of Information Act (FOIA) lawsuit brought by the Electronic Frontier Foundation (EFF), provide one of the most detailed looks yet at the federal government's Wasteful and Inappropriate Service Reduction (WISeR) model, a Medicare initiative launched in January that relies on AI-assisted reviews for certain medical procedures. EFF is suing the Centers for Medicare & Medicaid Services (CMS) to force the agency to disclose records regarding its use of AI in Medicare.
Medicare inserted AI into prior authorization before parts of the technology and the surrounding process were fully tested and working together,” Michael Ryan, a finance expert and the founder of MichaelRyanMoney.com, told Newsweek. When a request that is supposed to take 72 hours can sit unanswered for weeks, that is no longer administrative efficiency. For the beneficiary, it is delayed treatment.” Newsweek reached out to the CMS for comment via email.
The WISeR program is so far one of the federal government's most ambitious attempts to incorporate AI into Medicare administration. The pilot is operating in six states, including Texas, Arizona, New Jersey, Ohio, Oklahoma and Washington, and covers 13 medical services that the CMS identified as vulnerable to fraud, waste or inappropriate use. Before treatment, providers must obtain authorization through tech platforms operated by private contractors that use AI tools to help evaluate requests.
According to documents released through EFF's lawsuit, the program has experienced widespread operational problems since its launch. EFF said internal records show "widespread delays" in responses to authorization requests despite CMS stating that participating vendors should generally respond within 72 hours. The organization said the documents reveal long wait times and technical failures, with one request that went unanswered for 83 days.
There have also been inappropriate denials and reports of patient harm. The organization also said that the documents raise significant questions about how thoroughly the AI systems were tested before deployment. Although CMS says that a qualified human clinician must review all denials, research has shown that AI-generated recommendations often influence human decisions.” In response to concerns over how AI could complicate or worsen healthcare for seniors, CMS said previously it will work to update its model based on doctor and patient concerns.
A June investigation by KFF Health News found that some patients experienced long waits, confusion and additional travel requirements after WISeR introduced prior authorization rules into traditional Medicare. Providers described the rollout as "horrendous," while medical organizations said doctors were forced to rapidly adapt to new administrative requirements. Longer approval times mean patients may not get the care they need when they need it,” Thompson said, adding that he believes the CMS will continue to expand the WISeR model and sell it as a cost-saving tool “regardless of the outcomes.” One of the central issues highlighted by EFF is whether CMS adequately evaluated the technology before launching the program.
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