The Centers for Medicare & Medicaid Services (CMS) is set to launch a new pilot program on January 1, 2026, that will use artificial intelligence to review and approve certain medical services for Medicare beneficiaries. The program, named Wasteful and Inappropriate Service Reduction (WISeR), will operate in six states and is intended to run through 2031, raising questions among medical professionals about its potential impact on patient care.
Key Takeaways
- A new Medicare pilot program, WISeR, will use AI to process prior authorization requests for medical care.
- The program is scheduled to begin on January 1, 2026, and will affect beneficiaries in Arizona, Ohio, Oklahoma, New Jersey, Texas, and Washington.
- CMS aims to reduce costs and administrative tasks, but physicians and patient advocates express concern over potential increases in care denials.
- The system will include human oversight, and vendors will be prohibited from having compensation tied to denial rates.
Details of the WISeR Pilot Program
The Trump administration has outlined plans for the Wasteful and Inappropriate Service Reduction (WISeR) initiative, a five-year pilot program designed to modernize the prior authorization process within Medicare. Beginning in 2026, the program will be implemented across Arizona, Ohio, Oklahoma, New Jersey, Texas, and Washington.
According to CMS, the goal of using AI technology is to "help ensure people with Medicare receive the most appropriate care that supports the best health outcomes." The agency also states the program aims to decrease costs and reduce the administrative burden on healthcare providers who navigate the existing prior authorization system.
The use of automated systems for care approval is not new. It is already a common practice in the private health insurance sector, particularly among Medicare Advantage plans, where it has generated mixed results and significant debate.
Understanding Prior Authorization
Prior authorization is a process where healthcare providers must obtain approval from an insurer before a specific medical service, prescription, or procedure is delivered to a patient. The purpose is to control costs by ensuring the requested care is medically necessary. However, the process is often criticized by doctors and patients for causing delays and creating barriers to treatment.
Existing Landscape of Care Approvals
The debate surrounding WISeR is rooted in existing frustrations with prior authorization. A recent survey from the Kaiser Family Foundation (KFF) found that 73% of people believe delays and denials of treatment by health insurers are a major problem in the U.S. healthcare system.
Medicare Advantage plans, which are private plans that contract with the federal government, rely heavily on this process. A 2025 KFF report revealed that these plans made nearly 50 million prior authorization decisions in 2023 alone. The same report found that 99% of enrollees in a Medicare Advantage plan are subject to prior authorizations for at least some services.
Denial Rates in Focus
In 2023, Medicare Advantage plans denied 6.4% of all prior authorization requests. While this marked a slight decrease from the 7.4% denial rate in 2022, it still represents millions of instances where requested care was not approved initially.
The primary concern among critics is that introducing an AI-driven system like WISeR could exacerbate this issue, leading to a higher volume of denials and making it more difficult for older Americans to access necessary medical care.
Safeguards and Lingering Concerns
CMS has stated that the WISeR program will incorporate several safeguards to protect patients. Officials have confirmed that human clinical review will remain part of the process, ensuring that AI algorithms are not the sole decision-makers on complex medical cases.
Additionally, certain critical services will be exempt from the AI assessment. These include:
- Inpatient-only services
- Emergency care
- Any treatment that would pose a significant risk to a patient if delayed
To address concerns about financial incentives, CMS spokesperson Alexx Pons noted that vendors participating in the program will be "prohibited from compensation arrangements tied to denial rates." This measure is intended to prevent companies from profiting by denying medically appropriate care.
"The fear is that the new pilot program...will result in an increase in denials."
Despite these assurances, skepticism remains within the medical community. A 2025 survey by the American Medical Association found that 61% of physicians are worried that their health plans' current use of AI is already leading to more prior authorization denials. This existing distrust suggests that the WISeR program may face significant scrutiny from providers who fear it will add another layer of complexity to their work and potentially harm patient outcomes.
How Medicare Beneficiaries Can Prepare
For Medicare enrollees, particularly those in the six pilot states, the introduction of the WISeR program underscores the importance of being a proactive healthcare consumer. If you are concerned about how this AI system might affect your care, there are several steps you can take to protect yourself.
Key Actions for Patients
- Stay Informed: Keep up with news and updates about the WISeR program, especially in your state. Understanding the challenges others may be facing can help you anticipate and avoid them.
- Document Everything: Maintain detailed records from your healthcare providers regarding any medical issue. If a treatment is denied, request a formal written explanation from your insurer to review with your doctor.
- Understand Your Plan: Carefully read your Medicare plan's "Evidence of Coverage" document. This outlines what the plan covers and what costs you can expect, serving as a crucial reference point.
- Know the Appeals Process: All Medicare Advantage plans have a formal appeals process for denied claims. Typically, you have a 30-day window for a pre-service appeal and 60 days for a payment-related appeal. In urgent situations, you can request an expedited decision within 72 hours.
- Communicate Directly: If you live in a pilot state, speak with your Medicare plan administrator and your doctors about your concerns. Ask your insurer what criteria will be used for prior authorization decisions.
Finally, choosing healthcare providers who are thorough and willing to advocate on your behalf is more important than ever. A provider who will challenge a denial and navigate the appeals process can be a critical ally in ensuring you receive the care you need.