US Health Agency to Deploy AI for Medicare Claims Approval, Raising Concerns Over Patient Care and Denials

US Health Insurance Agency to Use AI for Authorizing Patient Claims: Potential Issues Ahead

The Centers for Medicare and Medicaid Services (CMS) is set to launch an AI-driven pilot program across six states by 2026. This initiative, called the WISeR Model, will use artificial intelligence to evaluate the appropriateness of medical services for Original Medicare recipients. Its goal is to cut down on wasteful or unnecessary care by speeding up prior authorization processes through AI algorithms.

CMS, the federal agency overseeing health insurance services in the US, announced this new AI pilot program to assess certain medical services for Original Medicare beneficiaries. The pilot will apply prior authorization requirements, a measure already common in Medicare Advantage plans, but new to Original Medicare on this scale.

How the WISeR Model Works

The WISeR Model is designed to partner with technology firms specializing in enhanced AI tools. These technologies aim to streamline the prior authorization process for select items and services that are particularly vulnerable to fraud, waste, abuse, or inappropriate use.

According to CMS, the program will help patients and providers avoid unnecessary care and protect federal taxpayer dollars by expediting approvals for medically appropriate services. The AI algorithms will determine if the requested care aligns with established medical guidelines and standards.

Concerns Surrounding AI in Prior Authorization

Despite the efficiency gains, this approach raises several concerns. Similar AI-based claim assessment tools have faced legal challenges in the past. Critics argue that AI companies involved could have strong financial incentives to deny claims, potentially limiting patient access to necessary care.

Some reports have gone as far as labeling the program "AI death panels," reflecting fears about automated systems making critical healthcare decisions without adequate human oversight.

What CMS Says About the Program

CMS stated: “The Centers for Medicare & Medicaid Services (CMS) is announcing a new Innovation Center model aimed at helping ensure people with Original Medicare receive safe, effective, and necessary care. Through the Wasteful and Inappropriate Service Reduction (WISeR) Model, CMS will partner with companies specializing in enhanced technologies to test ways to provide an improved and expedited prior authorization process relative to Original Medicare’s existing processes, helping patients and providers avoid unnecessary or inappropriate care and safeguarding federal taxpayer dollars.”

The agency emphasizes that this pilot will test whether AI and other enhanced technologies can improve the efficiency and accuracy of prior authorization, especially for services prone to misuse.

What Insurance Professionals Should Consider

• AI-driven prior authorization could significantly speed up claims processing, reducing administrative burdens.
• There is a risk that automated denials could increase, impacting patient access and satisfaction.
• Legal challenges and regulatory scrutiny may arise, affecting how insurers and providers adopt these tools.
• Insurance professionals should stay informed about the pilot’s progress and its implications for claims management.

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