Congress Moves to Halt Medicare AI Prior Authorization Program Active in Arizona

Criticism continues to mount against the Trump administration’s plan to use AI-based prior authorization for Medicare claims. The Wasteful and Inappropriate Service Reduction (WISeR) model, now active in Arizona and five other states, has already generated reports of delayed care for seniors since its January launch. On Tuesday, a House committee voted unanimously to halt the program.

The Centers for Medicare and Medicaid Services (CMS) insist the Medicare experiment will demonstrate an effective means of rooting out waste, but Medscape argues that it fundamentally alters the functionality of the Medicare program. The simplicity of tradition Medicare determines its value, but prior authorization is a strict tool for utilization control. Providers are also pressured into participation, facing pre-payment medical review with a far more burdensome administrative load.

Congressman Greg Landsman (D-Ohio) and Congresswoman Suzan DelBene (D-Wash.) announced they would lead a Congressional Review Act resolution for the use of AI in the WISeR model. Last month, the Government Accountability Office (GAO) determined the model would be subject to the act, meaning that it required congressional approval prior to implementation. From Congresswoman DelBene:

This program implements the same flawed prior authorization scheme from Medicare Advantage into traditional Medicare. If scaled up, it would be a back door to privatizing Medicare. It is causing needless delays, worsening conditions, and costing us more in the long-run. Congress needs to step up and put an end to WISeR.

On Tuesday, the House Appropriations Committee cleared a bill for a floor vote that will block the program from continuing. Modern Healthcare explains that the bill will need to be reconciled into the season’s appropriations package, but it has thus far received broad support from both sides of the aisle. Simply, the bill would prevent CMS from using Congressional funding for WISeR or “any such model that implements prior authorizations in traditional Medicare.”

The model is also facing court challenges. In March, the Electronic Frontier Foundation (EFF) filed against the agency for failing to answer a Freedom of Information Act (FOIA) request for records related to the AI used in the model, such as the vendor relationship and actual performance results of the WISeR model. According to law firm Crowell, EFF alleges that the AI-driven review has produced inappropriately high denial rates.