Medicare's new AI experiment sparks alarm among doctors, lawmakers

[marmar]

A Medicare pilot program will allow private companies to use artificial intelligence to review older Americans’ requests for certain medical care — and will reward the companies when they deny it.

In January, the federal Centers for Medicare & Medicaid Services will launch the Wasteful and Inappropriate Services Reduction (WISeR) Model to test AI-powered prior authorizations on certain health services for Medicare patients in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington. The program is scheduled to last through 2031.

The program effectively inserts one of private insurance’s most unpopular features — prior authorization — into traditional Medicare, the federal health insurance program for people 65 and older and those with certain disabilities. Prior authorization is the process by which patients and doctors must ask health insurers to approve medical procedures or drugs before proceeding.

Adults over 65 generally have two options for health insurance: traditional Medicare and Medicare Advantage. Both types of Medicare are funded with public dollars, but Medicare Advantage plans are contracted through private insurance companies. Medicare Advantage plans tend to cost less out of pocket, but patients enrolled in them often must seek prior authorization for care. .....................(more)

https://michiganadvance.com/2025/12/04/repub/medicares-new-ai-experiment-sparks-alarm-among-doctors-lawmakers/

[dalton99a]

1. Kick

[Bettie]

2. They get paid to avoid providing care

From the article: "The companies get paid based on how much money they save Medicare by denying approvals for “unnecessary or non-covered services,” CMS said in a statement unveiling the program."

Sounds like those Death Panels the right wing was so alarmed about...weird how okay they are with it when it's their guys setting them up.

[OldBaldy1701E]

5. Isn't it, though! (n/t)

[WmChris]

3. Traditional

There are also traditional supplements that are not disadvantage plans. Those who got suckered into the disadvantage plans soon find out they are not what was promised in the false advertisements.

[Faux pas]

4. Kicking with DISGUST!!!!

[ColoringFool]

6. One Goal Is Likely To Deny Coverage For Diabetes 2 And Its Related...

infirmities, basing the blanket denial on a "patient-caused condition" assertion.

[Joinfortmill]

8. Jeezus.

[Martin68]

7. Any use of AI in a customer service context is to be feared. "Speak to a representative" is my answer to what I want to

talk about when faced with bots or recordings.

[SergeStorms]

12. AI learns that there's a reward for denying coverage.

Ergo, AI will deny coverage as often as possible in order to be rewarded. Pavlov's dogs, anyone?

[IronLionZion]

19. AI finds it more cost efficient to let us die faster

Think of the great tax cuts for billionaires.

[Nigrum Cattus]

9. there is help for patients

https://www.counterforcehealth.org/

[mahina]

13. Could you please elaborate for those of us who are not inclined to readily click links?

Four paragraphs or so? Thank you very much!

[BComplex]

16. Wow! Thanks Nigrum Cattus! That's a great source for fighting insurance denials!

Never heard of it before this!

[Ms. Toad]

20. The problem isn't the availability of an appeal -

It is the denial in the first place.

One of those procedures in this new program is one I've had - for surgery on an extremely aggressive cancer. In my case, the tumor size doubled with 2-3 weeks. Appeals take months. I've had one take close to a year. Surgery could not proceed until all prior approvals were in place - OR - I agreed to pay for it myself. A delay of close to a year would have meant death.

Medicare has prior approval for treatments which are cosmetic in nature, but occasionally also medical. Although doctors should be able to determine with their patients what is medically necessary, it is understandable that - for example - the eyelid lift my spouse had because her eyelids were limiting her primary vision and were interfering with her peripheral vision - is also one my SIL wants for cosmetic reasons. Given the financial incentive for doctors to perform the surgery and call it medically necessary (rather than cosmetic - which would put it out of my SIL's budget), I can see wanting a second set of eyes on it. They should be real eyes, not AI eyes. But there is some actual basis for the procedures which currently require prior approval.

These new procedures are medically necessary - I didn't see any which were purely cosmetic. That, alone, makes it inappropriate as part of standard Medicare - even if the denials are done by humans. And even if there are appeals available. And even if there is a group willing to help with appeals.

[IronLionZion]

10. Arizona is a swing state with lots of retirees

they may want to vote blue next election since MAGA wants to deny Medicare treatment

[BComplex]

17. They will likely never hear about it, or understand it was REPUBLICANS who passed this

through. When the right owns/controls 96% of all media in the United States, getting people educated on who is screwing them over is difficult at best!

[popsdenver]

11. If they are looking for fraud and corruption instead

THAT would bring medicare costs down......For instance the CEO of a firm in Florida, that bilked medicare out of 1.4 Billion dollars, and instead of sending him to prison, they elected him U.S. Senator

[orangecrush]

14. They want us dead

That's been obvious for a while now

[BComplex]

15. Who in the F*** authorized this change??

Did any democrat approve this????

[Silent Type]

18. Medicare has used private contractors to review claims since at least 1980. The pilot program is limited to 6 states

and was originally mentioned during Biden's admin, though not formally adopted.

It's also limited to procedures with a high probability of overutilization and failure to meet Medicare's guidelines like-- Was conservative therapy tried first, etc.

They've been doing that for decades, but after payment in most cases. That's why you see fraud cases that go on for years before Medicare realizes it's someone offshore who never even provided the service or some doc who makes big money off questionabe wound tissue.

Within 6 months of the pilot, I bet some procedures are removed from prior approval list and they'll find ways to indicate coverage guidelines have been met, perhaps with certain modifiers to indicate conservative therapy and other coverage guidelines.

If you don't think providers -- including doctors -- don't cheat, you haven't been paying attention.

[Ms. Toad]

21. Requiring conservative therapy is a Medicare Advantage/Insurance concept - it has no place in Standard Medicare

The procedures which already require prior approval are those which are predominantly not medically necessary - but occasionally are. That is not the standard for this new list. Requiring prior approval for one of the items on the new list would likely have resulted in denial - and my death.

When Medicare denies something AFTER the fact, it is the medical provider who pays the cost - not the patient. My spouse's blepharoplasty was medically necessary (her eyelids were severely impairing her vision). That procedure was recently added to the list, and the doctor who performed it didn't obtain prior approval. The doctor was prohibited from passing any costs on to my spouse.

In this new list, it is the patient who will bear the cost - in human suffering and potentially death - because when the medically necessary procedures, with no cosmetic use, on this new list are inappropriately denied, the time it takes to win an appeal may well mean the difference between life and death.

Punish the doctors who are misbehaving. Don't take it out on their patients.

This is NOT appropriate, so please stop trying to justify it.

[Silent Type]

22. Absolutly incorrect. Original Medicare has extensive coverage policies. No, the patient won't pay because it'll be

denied if it doesn't meet requirements (docs can appeal), then the patient can decide whether to get the non-covered procedure/service.

It's very appropriate. There are no services on the list that are "life or death." And everyone of them has a Medicare coverage policy, either National (NCD) or Local (LCD which could be as many as 10 states with other states following policy).

A total of 17 types of procedures will now need prior approval. These services are often flagged for being overused or not always medically necessary. Here's what’s on the list:

Electrical Nerve Stimulators (NCD 160.7)
Sacral Nerve Stimulation for Urinary Incontinence (NCD 230.18)
Phrenic Nerve Stimulator (NCD 160.19)
Deep Brain Stimulation for Essential Tremor and Parkinson’s Disease (NCD 160.24)
Vagus Nerve Stimulation (NCD 160.18)
Induced Lesions of Nerve Tracts (NCD 160.1)
Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (LCDs L38307, L38312, L38385)
Epidural Steroid Injections for Pain Management (excluding facet-joint injections) (LCDs L39015, L39242, L36920)
Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (LCDs L34106, L38201, L35130)
Cervical Fusion (LCDs L39741, L39762, L39793)
Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee (NCD 150.9)
Incontinence Control Devices (NCD 230.10)
Diagnosis and Treatment of Impotence (NCD 230.4)
Percutaneous Image-Guided Lumbar Decompression for Spinal Stenosis (NCD 150.13)
Skin and Tissue Substitutes (general category)
Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds (LCD L35041)
Wound Application of Cellular and/or Tissue-Based Products (CTPs), Lower Extremities (LCD L36690)

Look up everyone of those and see how many fraud or abusive billing practices have been filed for the services. I have no problem punishing docs who cheat Medicare and patients with questionable treatments.

[LudwigPastorius]

23. Trump's government...

Too lazy to man its own death panels.

[IcyPeas]

24. It's bad enough when some employee at an insurance company who is not a doctor

can deny care, now AI will be doing it!?!?!

Why do we, the people, have to jump through hoops for medical care? People with medical problems have enough on their plates without having to deal with this shit.

Only in america.