A recent Medicare pilot program integrating artificial intelligence (AI) into prior authorization processes has resulted in significant treatment delays and concerns about insufficient testing. These findings emerged from government records released through a Freedom of Information Act (FOIA) lawsuit filed by the Electronic Frontier Foundation (EFF). The records provide a detailed view of the Wasteful and Inappropriate Service Reduction (WISeR) model, a Medicare program initiated in January utilizing AI for certain medical procedure reviews.
EFF is pursuing legal action against the Centers for Medicare & Medicaid Services (CMS) to compel the agency to release details about AI application in Medicare. According to Michael Ryan, a finance expert and founder of MichaelRyanMoney.com, AI was introduced into the authorization process without comprehensive testing. This has led to delays, contradicting the intended goal of improved administrative efficiency. Requests, which should be answered within 72 hours, have reportedly gone unanswered for weeks.
“The result is a faster way to create a bottleneck. When a request supposed to take 72 hours remains unanswered for weeks, it is no longer administrative efficiency. For the beneficiary, it is delayed treatment.” — Michael Ryan
The WISeR program represents a significant effort by the federal government to embed AI in Medicare administration. The pilot operates in six states—Texas, Arizona, New Jersey, Ohio, Oklahoma, and Washington—and targets 13 medical services prone to fraud, waste, or misuse. Providers must acquire authorization through platforms using AI tools, managed by private contractors.
Documents from EFF’s lawsuit indicate widespread operational challenges. CMS states responses should be provided within 72 hours, yet internal records show extensive delays, with some requests unanswered for up to 83 days. Additionally, there have been inappropriate denials and reports of patient harm. Kevin Thompson, CEO of 9i Capital Group, highlights the impact of insufficient testing on the delays seen in the program.
“The systems were not thoroughly tested prior to launch, causing delays beyond the 72-hour turnaround.” — Kevin Thompson
EFF stated the documents bring to light issues such as delay in securing approvals for essential procedures and problems with system outages. The organization emphasizes that without strict safeguards, AI-driven decisions may lead to unwarranted delays or denials in essential medical care.
CMS acknowledges concerns over AI’s role in healthcare, particularly for seniors. The agency committed to refining its model based on feedback from doctors and patients. A statement on its WISeR FAQ page affirms CMS’s dedication to ensuring accuracy, timeliness, and transparency in their model, pledging corrective actions to address issues.
A June investigation by KFF Health News revealed similar criticisms. Patients faced delays, confusion, and extra travel requirements after WISeR introduced prior authorization rules into traditional Medicare. Providers described the rollout as problematic, with organizations pointing to the strain on healthcare professionals adapting to new bureaucratic processes.
One pivotal issue, as EFF highlighted, is whether CMS rigorously validated the technology pre-launch. Their initial FOIA request sought details about testing for accuracy, potential biases, and compliance with auditing standards. EFF stresses the need for transparency, as AI recommendations significantly influence human decisions in the authorization process.
“Records released thus far echo concerns that providers have raised since WISeR launched, including long delays, financial incentives to deny care, and technical problems.” — EFF
Despite the challenges, expansion of AI use in Medicare seems imminent. Michael Ryan notes that the WISeR program is set to continue through 2031. Although AI’s role in speeding and securing healthcare is recognized, expanding its use without ensuring consistent outcomes in care efficiency may counter intended benefits.