"U.S. Health and Human Services Secretary Robert F. Kennedy Jr. (L) talks with Administrator for the Centers for Medicare & Medicaid Services Dr. Mehmet Oz while President Donald Trump delivers remarks in the Oval Office at the White House on November 6, 2025, in Washington, D.C. Andrew Harnik / Getty Images A Medicare pilot program will allow private companies to use artificial intelligence to review older Americans' requests for certain medical care - and will reward the companies when they deny it."
"The program effectively inserts one of private insurance's most unpopular features - prior authorization - into traditional Medicare, the federal health insurance program for people 65 and older and those with certain disabilities. Prior authorization is the process by which patients and doctors must ask health insurers to approve medical procedures or drugs before proceeding. Adults over 65 generally have two options for health insurance: traditional Medicare and Medicare Advantage."
"Medicare Advantage plans tend to cost less out of pocket, but patients enrolled in them often must seek prior authorization for care. AI-powered prior authorization in Medicaid Advantage and private insurance has attracted intense criticism, legislative action by state and federal lawmakers, federal investigations and class-action lawsuits. It's been linked to bad health outcomes. Dozens of states have passed legislation in recent years to regulate the practice."
A federal pilot called the Wasteful and Inappropriate Services Reduction (WISeR) Model will test AI-powered prior authorizations for certain Medicare services in six states beginning in January and running through 2031. The model allows private companies to review requests for care for Medicare patients and provides financial incentives when companies deny services. The program extends prior authorization practices into traditional Medicare, affecting beneficiaries aged 65 and older and people with certain disabilities. Medicare Advantage already uses prior authorization more frequently. AI-driven prior authorization in private programs has faced criticism, investigations, lawsuits and new state regulations due to reported harms.
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