"Government-backed plans like Medicare, however, have tended to cover what private insurers don't, and without the laborious application process. But that could be poised to change. The Centers for Medicare and Medicaid Services said it'll experiment with its own version of prior authorization by using AI models to screen claims, as part of its new belt-tightening program called the Wasteful and Inappropriate Service Reduction model, or WISeR."
"For now, the program, which begins in January, will be limited to six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington. Officials assert that the AI tools will only be used to judge claims for about a dozen different types of procedures it deems to be wasteful and providing little benefit, including steroid shots to relieve pain, per the ."
Private insurers commonly require prior authorization and frequently deny claims, sometimes using AI tools. Medicare historically covered services without such gatekeeping, but CMS will pilot AI-driven prior authorization under the WISeR program. Selected AI vendors will screen claims and receive a portion of savings from services they block, potentially amounting to billions over six years. The pilot starts in January across six states and targets roughly a dozen procedures while excluding emergency services and hospital stays. Officials describe narrow limits, but critics warn that vendor payment linked to savings creates strong incentives to deny care and to expand the program.
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