Medicare is set for a hi-tech makeover that might radically alter the way that seniors receive approval for their medical procedures. Beginning this January, the Centers for Medicare & Medicaid Services (CMS) will start piloting the use of artificial intelligence in order to make decisions about whether or not patients receive coverage for certain treatments and procedures.
The new program, the Wasteful and Inappropriate Service Reduction (WISeR) Model, is a major change for traditional Medicare, long requiring many fewer prior authorizations than Medicare Advantage. While CMS promises that human beings will have the final word, critics worry this would increase the rate of denials and delay for emergency-ill seniors.
The system will initially concentrate on three distinctive categories of procedures: tissue and skin substitutes, electric nerve-stimulator implantation, and knee arthroscopy for osteoarthritis of the knee. The system will consider requests and render recommendations, while a human worker will always make the final determination whether to approve or reject coverage.
Medicare’s AI Overhaul, Efficiency vs. Elder Care Concerns
The pilot program covers just six states today: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. The test would run for six years and would not extend to high-risk procedures that would not be safe to delay or any inpatient-only service.
The contrast between traditional Medicare and Medicare Advantage is remarkable. Medicare Advantage members had an average of two prior authorizations in 2023 and traditional Medicare members had one review for each 100 members. This new computer system could possibly bridge that gap and raise more scrutiny for traditional Medicare procedures.
The timing coincides with increasing Medicare expenses. Part B premiums will rise by $21.50 per month next year, increasing from $185 in 2025 to $206.50 in 2026. The Trump administration has placed a priority on curbing government waste and fraud, and that helps account for the move toward AI-augmented decision-making.
The program was defended by CMS Administrator Dr. Mehmet Oz, who said it will “crush fraud, waste, and abuse” and put Medicare into the 21st century. Dr. Oz noted that the system will bring together “the speed of technology and seasoned clinicians” in order to streamline the process.
Yet, experts are calling out a warning. Kevin Thompson, CEO of the 9i Capital Group, believes that the effect on the senior community would be significant, particularly when it’s a matter of immediate treatment. “What once required a single prior authorization may now have multiple layers, and that translates into more delays and higher denial volumes,” Thompson stated.
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The problem isn’t just one of delay it’s one of dollars. In this situation, critics comment that the companies actually doing reviews have a monetary incentive for withholding coverage since they are paid for cuts. “If contractors are rewarded for removing or withholding coverage, that is exactly what will happen,” warned Thompson.
Most concerning of all might be what we already know about AI and healthcare coverage decisions. A report from a Senate committee in 2024 discovered that.ai tools have a denial rate that is a whopping 16 times greater than decisions involving no technology. This figure by itself has many seniors and their representatives fearful for what lies ahead.
Alex Beene, a personal finance instructor at the University of Tennessee at Martin, was frank in his response: “Medicare beneficiaries desire a smooth process and as many obstacles eradicated as possible when qualifying and utilizing services. AI can definitely come into play and further define the process, yet as it has come forth, there are grounds for the alarm bells ringing.”
The next six years will determine whether or not this A.I. experiment truly makes it simpler for older Americans to access the medical attention that they need, or whether it provides yet one other barrier between patients and doctors. Until that time, pilot states should stay informed about their rights and be prepared for themselves in the event there are any unexpected delays or denials.
