Key facts
- A pilot program using AI to authorize or deny Medicare care, called WISeR, has faced criticism for delays and denials.
- The program aims to reduce fraud, waste, and abuse in Medicare payments.
- Healthcare providers have reported patients suffering in pain due to delayed care.
- One vendor, Virtix, denied 53% of prior authorization requests reviewed.
- The Government Accountability Office questioned the program's legality due to improper procedure.
- Lawmakers are attempting to get more documents released about the program.
The Trump administration's rollout of a pilot program utilizing artificial intelligence to manage Medicare claims has drawn significant criticism for its negative impact on seniors' access to care. The program, known as WISeR (Wasteful and Inappropriate Service Reduction), was implemented in January across six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington, with plans for expansion.
Healthcare providers have reported a range of issues, including technical difficulties, prolonged delays in decisions, and puzzling denials of necessary medical services. These problems have reportedly led to patients experiencing significant pain while awaiting authorization for treatments such as nerve stimulation, epidural steroid injections, and procedures for spinal compression fractures. One provider described the situation as "a disgrace to the human race."
Documents obtained by the Electronic Frontier Foundation through litigation revealed that the program's implementation was rushed and the technology was not fully ready. Vendors like Innovaccer initially asked for delays, with one vendor, Zyter, experiencing data discrepancies due to a misunderstanding of Medicare parts. Another vendor, Virtix, was found to be denying more requests than approving and was placed on a Corrective Action Plan by the Centers for Medicare & Medicaid Services (CMS) for failing to meet the 72-hour decision window. Virtix has since stated that its turnaround times have improved significantly and its CAP has ended.
Lawmakers have expressed concern, with Representative Suzan DelBene attempting to secure more documents related to WISeR, an effort that was blocked by Republicans. The Government Accountability Office has also questioned the program's legality, finding that proper procedures were not followed in its setup. Despite these criticisms and concerns, the program appears to be continuing.