Data from three hospital systems with 16 hospital locations across the state of Washington Association finds that the new Medicare pilot program that uses AI to process prior authorizations has led to longer delays, higher costs, and care denials.
A new Medicare pilot program that relies on artificial intelligence to approve or deny care is leading to significantly longer wait times, inconsistent claim denials, and increased administrative costs for hospitals and providers in Washington state, according to newly released data compiled by the Washington State Hospital Association (WSHA) and Sen. Maria Cantwell’s office. The findings echo a report released last month by WP Intelligence that found providers complained about high initial denial rates, workflow disruptions, and significant care delays.
RELATED: New report: Medicare WISeR prior authorization pilot program causing care delays
Sen. Maria Cantwell (D-Wash.) released the report this week following comments she made to Robert F. Kennedy Jr. during a Senate hearing about the Department of Health and Human Services’ proposed 2027 budget and concerns from her constituents about the Wasteful and Inappropriate Services Reduction (WISeR) Model. The pilot, which was launched on January 1 in six states, requires traditional Medicare patients to receive prior authorization for 13 medical services that previously didn’t require pre-approval. The claims are reviewed through a third-party system that uses AI and contractor clinicians to assess medical necessity. During his exchange with Cantwell, Kennedy said excessive delays are unacceptable and he will work with her office to fix it.
The latest report has found:
Wait times far exceed Medicare standards: Patients in Washington state are waiting two to four times longer for medically necessary procedures than they did prior to the pilot. Procedures that once took about two weeks from request to completion now often take four to eight weeks, primarily due to delayed authorization decisions. According to the Washington State Hospital Association (WSHA), authorization responses under WISeR frequently exceed CMS’ own timeliness standards, which require decisions within one day for urgent care and three days for routine requests. In practice, large systems such as the University of Washington Medical System report average response times of 15 to 20 days for both urgent and standard authorizations.
Shift in care decisions and clinical prioritization: Delays caused by the WISer model are altering how care is delivered, with hospitals increasingly scheduling procedures based on when authorization is granted rather than on clinical urgency. WSHA survey data indicates that this shift has led to prolonged pain, reduced mobility, and worsening underlying conditions for some patients, particularly those seeking non‑opioid pain treatments such as epidural steroid injections. Hospital leaders warn that these delays may have unintended public health consequences. As access to non‑addictive pain management is slowed, some patients are turning to alternative pain control methods, including opioids, to cope with extended waiting periods.
Denials and a lack of transparency: Under the WISeR Model, claims are reviewed by a private contractor using AI‑driven processes combined with clinician review. Providers report that denials are often inconsistent with established clinical criteria and frequently lack clear explanations, making appeals more time‑consuming and difficult to navigate. In Washington, the pilot is administered by Virtix Health, a CMS contractor that restricts access to claim updates to the individual staff member who submitted the authorization request. Hospitals report that this limitation creates operational bottlenecks when staff are unavailable and contributes to longer approval timelines.
The report also claims that the model is prioritizing profits over care because third-party administrators receive a financial bonus for each claim they deny under the assumptions that the denials account for prevention of wasteful spending.
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