AI-Driven Medicare Program Causing Delays and Denials, Sparks Lawsuit
In brief
- A new Medicare program using AI to evaluate prior authorization requests has led to widespread delays and denials of care, according to documents obtained through a lawsuit.
- The Wasteful and Inappropriate Service Reduction (WISeR) model, launched in January 2026, uses AI to assess whether certain medical services are necessary before approval.
- However, this system has caused significant issues for patients and healthcare providers, including improper denials and lengthy processing times that leave patients waiting for essential care.
- EFF filed a lawsuit earlier this year to gain transparency into the program's operations after reports of patient harm.
- The organization obtained over 1,000 pages of records showing that AI-driven decisions often lead to unwarranted delays or denials, potentially discrimination in access to care.
- Despite CMS assurances that human clinicians review all denials, research indicates AI recommendations heavily influence these decisions.
- The documents also reveal financial incentives for tech companies contracted by CMS, as they are paid based on reduced spending.
- This creates a conflict of interest, as vendors may prioritize cost-cutting over patient needs.
- As the program continues to face criticism and legal challenges, stakeholders are watching closely to see how CMS addresses these concerns and improves access to care for Medicare beneficiaries.
Terms in this brief
- Wasteful and Inappropriate Service Reduction (WISeR)
- A Medicare program using AI to evaluate prior authorization requests for medical services. It aims to assess necessity but has caused delays and denials, sparking legal challenges over potential discrimination and patient harm.
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