Medicare AI prior authorization test draws complaints over delays

A new Medicare prior authorization pilot using artificial intelligence is drawing complaints from patients and doctors who say it has delayed care and payments in six states. The program matters because traditional Medicare long avoided this private-insurance practice, and federal officials are testing it on services they say are prone to fraud or misuse.

The Wasteful and Inappropriate Service Reduction Model, known as WISeR, began in January in Oklahoma, Arizona, New Jersey, Ohio, Texas and Washington, according to the Centers for Medicare & Medicaid Services. It requires advance approval for 13 services, including epidural steroid injections, skin substitutes and kyphoplasty, a procedure used for spinal fractures.

CMS says the model is meant to reduce inappropriate care without slowing needed treatment. Abe Sutton, director of the Center for Medicare and Medicaid Innovation, said in a statement that the agency wants prior authorization to be efficient, fast and streamlined.

Patients and clinicians interviewed by KFF Health News described a rough start marked by confusion, errors, long waits and stress. Some doctors said the process has brought traditional Medicare patients into the same administrative burden often associated with private insurers.

Bill Curry, a 65-year-old cattle farmer in rural Oklahoma, told KFF Health News he has long driven 2½ hours to Oklahoma City each quarter for an epidural injection to treat back pain. This year, he said, he learned during one trip that he needed preapproval, then returned weeks later for the injection, totaling 10 hours on the road. He said his clinic also wanted a third visit to complete paperwork, which he has not made.

The program moved quickly by federal standards. CMS announced WISeR in June 2025 and launched it in mid-January. Todd Baker, who recently stepped down as CEO of the Ohio State Medical Association, told KFF Health News the timeline was faster than usual, while Jeb Shepard of the Washington State Medical Association said doctors had to work out the process as it began.

Vendors have also pointed to the speed of the launch. Dr. Jeremy Friese, CEO of Humata Health, the contractor for Oklahoma, told KFF Health News the rollout was aggressive from notification to go-live. Tech executives working in other states said in the spring that they were still adding product features.

CMS says decisions are returned within 72 hours and that clinicians receive a tracking number needed to schedule services and get paid. Friese said Humata’s system gives an immediate approval in 88% of cases when clinical data supports it.

Doctors and hospital officials reported slower results in practice. An April report from the office of Sen. Maria Cantwell, a Washington Democrat, citing hospital association data, said the University of Washington medical system had nearly 100 patients waiting earlier this year for epidural injections because of WISeR-related delays.

Clinicians also reported payment problems. Dr. James Webb, a musculoskeletal radiologist in Tulsa, Oklahoma, told KFF Health News he had seen six- to eight-week delays for kyphoplasty claims that should be paid within 15 days if there are no problems. Dr. Jerry Sobel, a pain management doctor near Phoenix, said that as of May he had not been paid by Medicare for nine epidurals.

Sundar Subramanian, CEO of Zyter, the Arizona contractor, said the company monitors operations and works with stakeholders to address questions and improve the provider experience. Sutton said payment backlogs are being resolved, without providing more detail.

Some doctors suspect AI-related mistakes in denials, though vendors say humans make final approval decisions. KFF Health News reported that one Arizona physician described a denial based on the wrong region of the spine, while Webb said one application was denied for numbness despite documentation that the patient did not have numbness. Friese said he had not heard of AI hallucinations.

Federal officials have cited fraud concerns behind the test. The Department of Health and Human Services inspector general warned in September that Medicare spending on skin substitutes had risen nearly 700% over two years, raising concerns about fraud, waste and abuse. Sutton also said the share of providers committing waste, fraud and abuse is small.

The pilot may also add costs through appeals. Sutton acknowledged that CMS has accounted for possible changes in Medicare appeal volume and related costs tied to WISeR. He said CMS is not currently considering changes to the list of services covered by the program, but continues to assess whether changes are warranted.

This story draws on original reporting from Medical Xpress.