Original Medicare’s new AI driven prior authorization pilot is creating care delays, operational strain, and provider dissatisfaction across six pilot states, according to an analysis by WP Intelligence, a new service offered by The Washington Post.
The Centers for Medicare & Medicaid Services (CMS) launched the Wasteful and Inappropriate Service Reduction (WISeR) model on January 1 to test whether artificial intelligence (AI) can speed up the prior authorization process for services considered vulnerable to fraud, waste, and abuse.
The six-year model is being tested in New Jersey, Oklahoma, Ohio, Washington, Arizona, and Texas and is meant to help patients and providers avoid unnecessary or inappropriate care while preventing wasteful spending. The program excludes services that pose a substantial risk to patients if significantly delayed and instead focuses on services such as skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy for knee osteoarthritis.
RELATED: New CMS model will test prior authorization in Original Medicare
The announcement about the pilot came as a surprise given that prior authorization in Medicare Advantage has ranked as the number one administrative burden facing medical groups. Members also complain that the need to get prior approval for services have led to delays or denial of care even when the requests have met Medicare coverage rules.
Although CMS positioned the program as a way to reduce waste and modernize utilization management, early implementation challenges highlight the complexity of deploying AI‑assisted review at scale in Medicare fee‑for‑service (FFS), WP Intelligence reports.
Indeed, providers taking part in the pilot and interviewed by the media outlet reported:
- High initial denial rates and requests for additional documentation.
- Increased return visits for elderly patients solely to bolster documentation.
- Workflow disruptions due to portal glitches, long phone hold times, and inconsistent communications with vendors.
- Significant care delays, even for pain management and minimally invasive procedures.
The media outlet also reports that several states experienced payment complications due to misalignment between tech vendors and Medicare Administrative Contractors (MACs):
- Prior authorization numbers issued by vendors weren’t accepted by MACs.
- Required UTNs (Unique Tracking Numbers) often arrived days late, leaving claims unpaid.
- Practices reported hundreds of thousands of dollars in delayed payments, creating financial instability—especially for independent groups.
Providers have also voiced concerns similar to the complaints heard within the Medicare Advantage industry: Long waits for peer‑to‑peer review, Inconsistent interpretation of clinical criteria, barriers to timely pain and musculoskeletal care, risk of emergency department utilization due to treatment delays.
One Arizona patient with severe back pain waited through two AI‑generated denials before eventually receiving relief, according to the report.
CMS said physicians can skip prior authorization if they are certain care is necessary. However, they will face a pre-payment review for the services.
Beginning in July, CMS intends to exempt high‑performing physicians (those with high authorization approval rates) from prior authorization. This move mirrors “gold carding” and selective prior authorization reduction strategies some Medicare Advantage plans already use.