Medicare AI Prior Authorization Pilot Delays Care for Washington Seniors
A federal pilot program using artificial intelligence to review Medicare prior authorizations is delaying patient care in Washington, according to a report released Wednesday by Sen. Maria Cantwell, D-Wash.
Under the WISeR program, procedures that previously received approval within two weeks now take four to eight weeks, according to survey data from the Washington State Hospital Association. The delays are forcing providers to add staff and increasing administrative burden, while potentially worsening health outcomes for patients waiting for treatment.
"It's basically taking weeks to find out you were denied," Cantwell said during a Senate Finance Committee hearing Wednesday.
How the Pilot Works
The Wasteful and Inappropriate Service Reduction model, announced by the Centers for Medicare & Medicaid Services last year, contracts with private companies to handle AI-backed prior authorization for specific procedures in six states, including Washington. Covered services include skin and tissue substitutes and epidural steroid injections for pain management.
This represents a significant shift. Traditional Medicare rarely requires pre-approval before providers administer certain services or medications.
Approval Timelines Missing Targets
The CMS set targets of three days for routine care responses and one day for urgent care. Washington providers are far exceeding those benchmarks.
At the University of Washington Medical System, prior authorization requests take an average of 15 to 20 days for responses. The health system has nearly 100 patients waiting for epidural steroid injections due to the delays.
System Design Creating Additional Friction
Virtix Health, the contractor administering the pilot in Washington, restricts access to authorization updates and documents to the employee who submitted the request. When staff members are out of the office, requests sit idle.
Hospitals also report that denials lack clear reasoning and frequently contradict clinical standards, according to the Washington State Hospital Association survey.
Federal Response
HHS Secretary Robert F. Kennedy Jr. told Cantwell during the hearing that waiting weeks for prior authorization responses was unacceptable and said the department would work to fix the issues.
Kennedy defended the pilot's purpose, saying Medicare was paying for procedures that were often unnecessary or fraudulent. "We found we were being ripped off by certain categories of procedures that are not good for the patient," he said, citing spending on skin substitutes that has increased sharply in recent years.
Tension With Broader Administration Goals
The delays stand in contrast to the Trump administration's stated goal of reducing prior authorizations overall. Major insurers have cut 11% of prior authorizations since committing to reductions last year.
For healthcare professionals managing these workflows, the WISeR pilot highlights the operational friction that can emerge when AI systems replace human review without adequate design for provider needs. Understanding how AI for Healthcare systems actually function in practice - versus how they're designed in theory - remains essential for anyone overseeing clinical operations.
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