The Trump Administration Is Planning to Use AI to Deny Medicare Authorizations

[douglas9]

The Trump Administration is bringing prior authorizations (PAs), the mandatory preapproval before insurance covers health care services, to Traditional Medicare. The government plans on using contracts with perverse incentives for companies that use artificial intelligence (AI) to carry out the work.

On June 27, the Centers for Medicare and Medicaid Services’ (CMS) Innovation Center announced a new public-private partnership model called the Wasteful and Inappropriate Service Reduction (WISeR) Model — lasting from 2026-2031. WISeR’s purpose is to reduce wasteful spending in Medicare. CMS cites the Medicare Payment Advisory Commission’s (MedPAC) finding that, in 2022, taxpayers financed $5.8 billion in low-value care, defined as “the provision of a service that has little or no clinical benefit or care in which the risk of harm from the service outweighs its potential benefit.”

The WISeR model will have CMS contract with “companies with expertise providing recommendations on medical necessity of coverage for payers using enhanced technology like AI.” While using AI, CMS will require that these companies have clinicians ultimately conduct reviews to validate medical determinations whether a product or service is wasteful. Prior authorizations currently exist for a relatively small number of services in Traditional medicare; however, WISeR will greatly expand these and work with companies with prior authorization experience in Medicare Advantage.

https://truthout.org/articles/the-trump-administration-is-planning-to-use-ai-to-deny-medicare-authorizations/