The Center for Medicare and Medicaid Innovation recently announced the launch of the Wasteful and Inappropriate Service Reduction (WISeR) Model in Medicare starting in 2026. This six-year demonstration project will allow for-profit contractors to utilize artificial intelligence tools to determine treatment protocols for elderly and certain disabled groups enrolled in traditional Medicare.
The WISeR model is based on a policy that has been successful in the privately run alternative to original Medicare, known as Medicare Advantage. While traditional Medicare uses prior authorization sparingly for outpatient services and durable medical equipment, Medicare Advantage plans rely heavily on prior authorization for a wide range of procedures and technologies. This often leads to delays in care and denials of certain treatments.
Critics of the WISeR model, including former Cigna executive Wendell Potter, have raised concerns about the potential impact on patient care and access to services. In response, six Democratic lawmakers have introduced legislation to block the implementation of the program.
Health insurers, including those offering Medicare Advantage plans, are increasingly turning to AI to assess the appropriateness and necessity of care for beneficiaries. They have pledged to improve pre-approval protocols for diagnostic tests, prescription medications, and procedures to streamline the process and ensure timely decisions.
While prior authorization can help ensure that treatments are appropriate and safe, there are concerns about the potential impact on patient care and outcomes. Plans may not save as much money as expected, as a significant number of prior authorization requests are overturned upon appeal.
Overall, the use of AI and prior authorization in healthcare has the potential to optimize the use of services and technologies. However, it is essential to strike a balance between cost-saving measures and ensuring that patients receive the care they need in a timely manner. With ongoing efforts to improve the prior authorization process, the goal is to create a more efficient and patient-friendly system that benefits both insurers and patients.
