AI prior authorization pilot could delay care for Ohio Medicare patients, critics warn

Medicare's WISeR pilot: What Ohio insurers need to prepare for

Ohio is one of six states tapped for the Wasteful and Inappropriate Service Reduction (WISeR) Model, a six-year Medicare pilot slated to begin in January. Traditional Medicare claims for select services will require prior authorization, with AI assisting reviews and human clinicians approving denials.

Funding is under congressional scrutiny, but stakeholders should plan for operational impacts now. Expect provider pushback, member anxiety, and increased demand for clear, fast decisions.

What changes under WISeR

• Traditional Medicare (not just Medicare Advantage) will require prior authorization for a defined set of services.
• AI tools will help evaluate requests; CMS says any denial will be approved by a licensed human clinician.
• Hospital stays, emergency services, and care where delays pose health risks are excluded.
• Targeted services accounted for up to $5.8B in 2022 spending, according to federal data.

Services likely to require prior authorization

• Skin and tissue substitutes
• Electrical nerve stimulator implants
• Knee arthroscopy
• Devices for incontinence control
• Cervical fusion
• Steroid injections for pain management
• Diagnosis and treatment of impotence

Why this matters for insurance professionals

• Original Medicare will start to resemble Medicare Advantage on prior auth - fewer differences to explain to providers and members.
• Higher volumes of prior auth submissions from physicians who have never done this under traditional Medicare.
• Appeals handling and turnaround times will face more scrutiny, especially for pain procedures.
• AI oversight and documentation expectations will rise, including bias mitigation and audit trails.

Stakeholder concerns you'll hear

Advocates say the pilot could delay or restrict medically necessary care for older adults. "It creates a barrier between what physicians and other healthcare providers order and want as medically necessary for their patients and what can be provided based on algorithms," said Judith Stein of the Center for Medicare Advocacy.

Some warn this blurs the line between traditional Medicare and Medicare Advantage. "It's a first step to getting rid of, or downgrading, the freedom that traditional Medicare provides," said Carrie Graham of Georgetown University's Medicare Policy Initiative.

Prior authorization: the tension points

• Pros: curbs ineffective or unnecessary care; targets outlier utilization.
• Cons: delays treatment, adds provider burden, and can shift costs to patients if timelines slip.

Data point: Nearly 1 in 5 insured adults reported a claim denial over 12 months in KFF's 2023 survey. Denial rates were about twice as high for private/ACA plans compared to Medicare or Medicaid, which were around 1 in 10.

Appeals reality check

In 2023, about 12% of Medicare Advantage prior authorization denials were appealed, and over 80% of those were overturned, said the Center for Medicare Advocacy. The majority never appeal due to complexity, illness, or lack of help from busy physicians.

Translation: clarity, simple workflows, and proactive support matter as much as clinical criteria.

AI's role - and risk management

• CMS indicates human clinicians will sign off on denials, not machines alone.
• Reports warn that algorithms trained on biased data can reinforce disparities; vendors may have savings-based incentives that skew decisions.

"While supposedly there is a clinician that's going to double check if the electronic AI says that this care shouldn't be covered, my experience tells me that doesn't happen in many instances," said Stein. Build safeguards that prove otherwise.

Action checklist for carriers, TPAs, and UM leaders

• Criteria alignment: Map clinical policies to CMS guidance for each targeted service; publish plain-language summaries for providers.
• Expedited pathways: Define fast-track reviews for cases where delay could worsen pain or function; document criteria for urgency.
• Provider enablement: Offer PA submission guides, checklists, and EHR tip sheets; host brief webinars for high-volume specialties (orthopedics, pain, urology, dermatology).
• Member communication: Create clear notices explaining what prior auth is, expected timelines, and appeal rights; add call center scripts.
• Appeals support: Simplify forms, accept multiple submission channels, and track turnaround; flag auto-escalation for vulnerable members.
• AI governance: Stand up a model oversight group; audit denial patterns by age, race, geography, and socioeconomic indicators; require human-in-the-loop verification with documented rationales.
• Vendor incentives: If using external AI, ensure contracts avoid pure "savings share" structures; tie incentives to accuracy, fairness, and timeliness.
• SLAs and metrics: Set targets for initial decision times, overturn rates, peer-to-peer availability, and provider satisfaction; review weekly during rollout.
• Compliance readiness: Maintain auditable logs of criteria used, evidence reviewed, and clinician sign-offs for every denial.
• Scenario planning: Prepare for congressional delays; run "on/off" playbooks so your teams can pivot quickly.

Communications you can deploy fast

• One-page provider explainer listing impacted CPT categories, documentation requirements, and decision timelines.
• Member FAQ on prior auth, including how to request an expedited review and how to appeal.
• Office staff checklist: what to include with initial requests to avoid back-and-forth (recent imaging, conservative therapy history, functional impairment measures).

Key numbers to keep in view

• More than 2.5 million Ohioans are enrolled in Medicare.
• About 56% of Ohio Medicare beneficiaries are in Medicare Advantage plans.
• Targeted services: up to $5.8B in 2022 spending.
• KFF 2023: nearly 1 in 5 insured adults saw a claim denial; Medicare/Medicaid denial rates around 1 in 10.
• Medicare Advantage 2023: ~12% of prior auth denials appealed; >80% overturned.

Watch this space

The pilot's funding and scope could shift with congressional action. Track CMS announcements and prepare to adjust criteria, timelines, and communications quickly.

Resources

• CMS Innovation Center
• KFF: Health policy analysis
• Complete AI Training: Courses by job (for teams building AI literacy and governance skills)

Bottom line

Prior authorization is expanding into traditional Medicare for select services in Ohio. Build clear criteria, fast review paths, strong appeals support, and real AI oversight - and you'll reduce denials that don't hold, cut friction with providers, and protect members from avoidable delays.