Key facts
- The Trump administration is piloting a program using AI to reduce unnecessary medical spending in six states.
- Physicians are concerned AI in prior authorization could lead to increased wrongful denials of necessary medical care.
- The American Medical Association is calling for greater transparency in AI algorithms used for insurance coverage decisions.
- A Commonwealth Fund survey indicated that approximately 20% of working-age adults with private insurance experienced a denial of recommended medical care in 2025.
- The WISeR demonstration project, utilizing AI, aims to decrease waste and fraud in original Medicare.
- Vendors participating in the WISeR model may profit from rejected care requests, raising concerns about profit motives.
The U.S. government is exploring the use of artificial intelligence to streamline the prior authorization process for medical care, a system widely criticized for causing delays and patient hardship. While AI theoretically could expedite approvals for straightforward claims, concerns are mounting that it may lead to an increase in wrongful denials of necessary treatments.
A 2025 American Medical Association survey revealed that 61 percent of physicians worry AI will worsen denials. The AMA advocates for insurers to provide detailed clinical reasoning for denials and greater transparency regarding AI algorithms. Health policy analyst Camm Epstein stated that AI should facilitate approval of appropriate care, not make it easier to deny necessary care.
The Trump administration is currently piloting a program in six states using AI to reduce unnecessary medical spending, with the Centers for Medicare and Medicaid Services (CMS) running a demonstration project called WISeR. This project aims to decrease waste and fraud in original Medicare by combining machine learning with human review for services potentially vulnerable to overuse. However, critics, including health insurance reform advocate Wendell Potter and researcher Zena Wolf, point to investigations suggesting the model has already caused care delays and denials in pilot states.
Prior authorization is a significant burden, particularly in Medicare Advantage plans, which issue millions of claim denials annually. A Commonwealth Fund survey found that about one in five working-age adults with private insurance experienced a denial of physician-recommended care in 2025, with many reporting delayed care or worsening health conditions as a result. While previous reforms aimed to speed up decisions, the expansion of AI into original Medicare through the WISeR model is drawing criticism, especially as vendors may profit from rejected claims. Several lawmakers are seeking to block funding for the WISeR model, citing threats to patient access, while CMS Administrator Mehmet Oz has urged private insurers to reduce prior authorization burdens.