![\"Dr.](\"https:\/\/www.europesays.com\/ie\/wp-content\/uploads\/2025\/09\/Dr-Oz.png\")
Getty Images<\/p>\n
But some critics, like Vinay Rathi, an Ohio State University doctor and policy researcher, have accused the Trump administration of sending mixed messages.<\/p>\n
\u201cIt erodes public trust in the health care system,\u201d Oz told the media. \u201cIt\u2019s something that we can\u2019t tolerate in this administration.\u201d<\/p>\n
\nIt\u2019s hugely concerning.<\/p>\n
Rep. Suzan DelBene<\/p><\/blockquote>\n
\u201cOn one hand, the federal government wants to borrow cost-cutting measures used by private insurance,\u201d he said. \u201cOn the other, it slaps them on the wrist.\u201d<\/p>\n
Administration officials are \u201ctalking out of both sides of their mouth,\u201d said Rep. Suzan DelBene, a Washington Democrat. \u201cIt\u2019s hugely concerning.\u201d<\/p>\n
Patients, doctors, and other lawmakers have also been critical of what they see as\u00a0delay-or-deny tactics<\/a>, which can slow down or block access to care,\u00a0causing irreparable harm and even death<\/a>.<\/p>\n
\u201cInsurance companies have put it in their mantra that they will take patients\u2019 money and then do their damnedest to deny giving it to the people who deliver care,\u201d said Rep. Greg Murphy, a North Carolina Republican and a urologist. \u201cThat goes on in every insurance company boardroom.\u201d<\/p>\n
Insurers have long argued that prior authorization reduces fraud and wasteful spending, as well as prevents potential harm. Public displeasure with insurance denials dominated the news in December, when the\u00a0shooting death of UnitedHealthcare\u2019s CEO<\/a>\u00a0led many to anoint his alleged killer as a folk hero.<\/p>\n
And the public broadly dislikes the practice: Nearly three-quarters of respondents thought prior authorization was a \u201cmajor\u201d problem in\u00a0a July poll published by KFF<\/a>, a health information nonprofit that includes KFF Health News.<\/p>\n
Indeed, Oz said during his June press conference that \u201cviolence in the streets\u201d prompted the Trump administration to take on the issue of prior authorization reform in the private insurance industry.<\/p>\n
Still, the administration is expanding the use of prior authorization in Medicare. CMS spokesperson Alexx Pons said both initiatives \u201cserve the same goal of protecting patients and Medicare dollars.\u201d<\/p>\n
Unanswered questions<\/p>\n
The\u00a0pilot program<\/a>, WISeR \u2014 short for \u201cWasteful and Inappropriate Service Reduction\u201d \u2014 will test the use of an AI algorithm in making prior authorization decisions for some Medicare services, including skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy.<\/p>\n
The federal government says such procedures are particularly vulnerable to \u201cfraud, waste, and abuse\u201d and could be held in check by prior authorization.<\/p>\n
Other procedures may be added to the list. But services that are inpatient-only, emergency, or \u201cwould pose a substantial risk to patients if significantly delayed\u201d would not be subject to the AI model\u2019s assessment, according to the federal announcement.<\/p>\n
While the use of AI in health insurance isn\u2019t new, Medicare has been slow to adopt the private-sector tools. Medicare has historically used prior authorization in a limited way, with contractors who aren\u2019t incentivized to deny services. But experts who have studied the plan believe the federal pilot could change that.<\/p>\n
\nI\u2019m not sure they know, even, how they\u2019re going to figure out whether this is helping or hurting patients.<\/p>\n
Dr. Vinay Rathi<\/p><\/blockquote>\n
Pons told KFF Health News that no Medicare request will be denied before being reviewed by a \u201cqualified human clinician,\u201d and that vendors \u201care prohibited from compensation arrangements tied to denial rates.\u201d While the government says vendors will be rewarded for savings,\u00a0Pons said multiple safeguards will \u201cremove any incentive to deny medically appropriate care.\u201d<\/p>\n
\u201cShared savings arrangements mean that vendors financially benefit when less care is delivered,\u201d a structure that can create a powerful incentive for companies to deny medically necessary care, said Jennifer Brackeen, senior director of government affairs for the Washington State Hospital Association.<\/p>\n
And doctors and policy experts say that\u2019s only one concern.<\/p>\n
Rathi said the plan \u201cis not fully fleshed out\u201d and relies on \u201cmessy and subjective\u201d measures. The model, he said, ultimately depends on contractors to assess their own results, a choice that makes the results potentially suspect.<\/p>\n
\u201cI\u2019m not sure they know, even, how they\u2019re going to figure out whether this is helping or hurting patients,\u201d he said.<\/p>\n
Pons said the use of AI in the Medicare pilot will be \u201csubject to strict oversight to ensure transparency, accountability, and alignment with Medicare rules and patient protection.\u201d<\/p>\n
\u201cCMS remains committed to ensuring that automated tools support, not replace, clinically sound decision-making,\u201d he said.<\/p>\n
Experts agree that AI is theoretically capable of expediting what has been a cumbersome process marked by delays and denials that can harm patients\u2019 health. Health insurers have argued that AI eliminates human error and bias, and will save the healthcare system money. These companies have also insisted that humans, not computers, are ultimately reviewing coverage decisions.<\/p>\n
But some scholars are doubtful that\u2019s routinely happening.<\/p>\n
\u201cI think that there\u2019s also probably a little bit of ambiguity over what constitutes \u2018meaningful human review,\u2019\u201d said Amy Killelea, an assistant research professor at the Center on Health Insurance Reforms at Georgetown University.<\/p>\n
A 2023\u00a0report published by ProPublica<\/a>\u00a0found that, over a two-month period, doctors at Cigna who reviewed requests for payment spent an average of only 1.2 seconds on each case.<\/p>\n
Cigna spokesperson Justine Sessions told KFF Health News that the company does not use AI to deny care or claims. The ProPublica investigation referenced a \u201csimple software-driven process that helped accelerate payments to clinicians for common, relatively low-cost tests and treatments, and it is not powered by AI,\u201d Sessions said. \u201cIt was not used for prior authorizations.\u201d<\/p>\n
And yet class-action lawsuits filed against major health insurers have alleged that flawed AI models undermine doctor recommendations and fail to take patients\u2019 unique needs into account, forcing some people to shoulder the financial burden of their care.<\/p>\n
Meanwhile, a\u00a0survey of physicians published<\/a>\u00a0by the American Medical Association in February found that 61% think AI is \u201cincreasing prior authorization denials, exacerbating avoidable patient harms and escalating unnecessary waste now and into the future.\u201d<\/p>\n
Chris Bond, a spokesperson for the insurers\u2019 trade group AHIP, told KFF Health News that the organization is \u201czeroed in\u201d on implementing the commitments made to the government. Those include reducing the scope of prior authorization and making sure that communications with patients about denials and appeals are easy to understand.<\/p>\n
\u201cThis is a pilot\u201d<\/p>\n
The Medicare pilot program underscores ongoing concerns about prior authorization and raises new ones.<\/p>\n
While private health insurers have been opaque about how they use AI and the extent to which they use prior authorization, policy researchers believe these algorithms are often programmed to automatically deny high-cost care.<\/p>\n
\nThe No. 1 thing to do is make it very, very difficult for people to get high-cost services.<\/p>\n
Jennifer Oliva<\/p><\/blockquote>\n
\u201cThe more expensive it is, the more likely it is to be denied,\u201d said Jennifer Oliva, a professor at the Maurer School of Law at Indiana University-Bloomington, whose work focuses on AI regulation and health coverage.<\/p>\n
Oliva explained in a recent\u00a0paper for the Indiana Law Journal<\/a>\u00a0that when a patient is expected to die within a few years, health insurers are \u201cmotivated to rely on the algorithm.\u201d As time passes and the patient or their provider is forced to appeal a denial, the chance of the patient dying during that process increases. The longer an appeal, the less likely the health insurer is to pay the claim, Oliva said.<\/p>\n
\u201cThe No. 1 thing to do is make it very, very difficult for people to get high-cost services,\u201d she said.<\/p>\n
As the use of AI by health insurers is poised to grow, insurance company algorithms amount to a \u201cregulatory blind spot\u201d and demand more scrutiny, said Carmel Shachar, a faculty director at Harvard Law School\u2019s Center for Health Law and Policy Innovation.<\/p>\n
The WISeR pilot is \u201can interesting step\u201d toward using AI to ensure that Medicare dollars are purchasing high-quality health care, she said. But the lack of details makes it difficult to determine whether it will work.<\/p>\n
Politicians are grappling with some of the same questions.<\/p>\n
\u201cHow is this being tested in the first place? How are you going to make sure that it is working and not denying care or producing higher rates of care denial?\u201d asked DelBene, who\u00a0signed an August letter<\/a>\u00a0to Oz with other Democrats demanding answers about the AI program. But Democrats aren\u2019t the only ones worried.<\/p>\n
Murphy, who co-chairs the House GOP Doctors Caucus, acknowledged that many physicians are concerned the WISeR pilot could overreach into their practice of medicine if the AI algorithm denies doctor-recommended care.<\/p>\n
Meanwhile, House members of both parties recently supported a\u00a0measure proposed by Rep. Lois Frankel<\/a>, a Florida Democrat, to block funding for the pilot in the fiscal 2026 budget of the Department of Health and Human Services.<\/p>\n
AI in health care is here to stay, Murphy said, but it remains to be seen whether the WISeR pilot will save Medicare money or contribute to the problems already posed by prior authorization.<\/p>\n
\u201cThis is a pilot, and I\u2019m open to see what\u2019s going to happen with this,\u201d Murphy said, \u201cbut I will always, always err on the side that doctors know what\u2019s best for their patients.\u201d<\/p>\n
KFF Health News<\/a>\u00a0is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF\u2014an independent source of health policy research, polling, and journalism. Learn more about\u00a0KFF<\/a>.<\/p>\n","protected":false},"excerpt":{"rendered":"Taking a page from the private insurance industry\u2019s playbook, the Trump administration will launch a program next year…\n","protected":false},"author":2,"featured_media":93755,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[275],"tags":[291,289,18,135,475,493,474,19,17,145],"class_list":{"0":"post-93754","1":"post","2":"type-post","3":"status-publish","4":"format-standard","5":"has-post-thumbnail","7":"category-healthcare","8":"tag-ai","9":"tag-artificial-intelligence","10":"tag-eire","11":"tag-health","12":"tag-health-care","13":"tag-health-insurance","14":"tag-healthcare","15":"tag-ie","16":"tag-ireland","17":"tag-medicare"},"share_on_mastodon":{"url":"","error":""},"_links":{"self":[{"href":"https:\/\/www.europesays.com\/ie\/wp-json\/wp\/v2\/posts\/93754","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.europesays.com\/ie\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.europesays.com\/ie\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.europesays.com\/ie\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.europesays.com\/ie\/wp-json\/wp\/v2\/comments?post=93754"}],"version-history":[{"count":0,"href":"https:\/\/www.europesays.com\/ie\/wp-json\/wp\/v2\/posts\/93754\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.europesays.com\/ie\/wp-json\/wp\/v2\/media\/93755"}],"wp:attachment":[{"href":"https:\/\/www.europesays.com\/ie\/wp-json\/wp\/v2\/media?parent=93754"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.europesays.com\/ie\/wp-json\/wp\/v2\/categories?post=93754"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.europesays.com\/ie\/wp-json\/wp\/v2\/tags?post=93754"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}