Additionally, vendors participating in the WISeR model, who were hired to carry out AI-driven prior authorization, earn a share of what CMS calls “averted expenditures.” This could entail revenues for rejecting care requests. In turn this points to a broader discussion about long-standing concerns regarding profit-making on the basis of discouraging patients from getting medically necessary care. Several lawmakers have introduced resolutions and amendments to block funding for the WISeR model, citing threats to patient access.
Yet the Trump administration seems to be of two minds when it comes to prior authorization. As CMS expands its use in original Medicare using AI, the agency wants to lessen and streamline its use by private insurers, including Medicare Advantage plans. CMS Administrator Mehmet Oz has warned insurance company executives that they must ease the burden of prior authorization, or the federal government will impose regulation: “If you don’t do it yourselves, then we’re going to do it for you,” he told the National News Desk, a TV news program.
Possibly to preempt further executive branch action or passage of laws by legislators, health plans released data recently that suggest they’re complying with administration demands. The industry-based survey reveals that between June 2025 and April 2026, requests for prior authorization declined by 11 percent. It’s unknown, however, whether the denial rate has decreased.
Responding to an industry group survey conducted last year, all responding health plans agreed with the statement, “AI or algorithms without clinician or practitioner review are not used to deny prior authorization requests that involve medical necessity or clinical considerations.” Moreover, insurers promised more transparency around clinical reasoning underlying prior authorization.
This may alleviate some of the worry about a lack of human review of decisions made by AI. But placating detractors won’t be easy.
Jared Dashevsky, a physician and founder of a media and educational platform called Healthcare Huddle, wrote that AI could “eliminate barriers, reduce administrative waste, give us more time with patients. But that’s not what’s being built.” Instead, he says, there’s an “arms race to deny faster and appeal faster. More automation of a broken system that shouldn’t exist in its current form.”
This article was originally published on Undark. Read the original article.
Be the first to comment