One vendor was put on a ‘corrective action plan’ for denying more claims than it approved A pilot program using artificial intelligence to approve care for Medicare beneficiaries has resulted in high levels of denials and delayed decisions and prompted warnings from a vendor about a lack of readiness, according to a lawsuit seeking information about the program. The program, called the Wasteful and Inappropriate Service Reduction model, or WISeR, was created with the aim of cutting costs and easing administrative burdens and is slated to run through the end of 2031 in six states. The Freedom of Information Act lawsuit, which was filed in March by the digital-rights organization Electronic Frontier Foundation against the Centers for Medicare & Medicaid Services, recently produced about 1,000 pages of documents detailing medical providers’ complaints about the program, contracts with technology vendors, and records of denials and delays of care.
Some of the information released under the lawsuit had been previously flagged by medical providers and lawmakers, but the extent of problems, the excessive denials by one vendor and the concerns raised before the launch by another vendor were not previously known. Don’t Short Yourself offers weekly money tips to help you earn it, stack it and grow it. I would like to receive updates and special offers from Dow Jones and affiliates.
I can unsubscribe at any time. The Freedom of Information Act is a U.S. law that gives anyone the right to request access to records from any federal agency. A FOIA lawsuit is a legal action filed in federal court when a government agency fails to properly fulfill or respond to a request for public records. **Read:**A new Medicare program that uses AI for prior authorizations is hurting patients and delaying care “There’s alarmingly high denial rates, and that is known by CMS,” said Lena Cohen, a staff technologist at EFF.
Many are waiting over a month to receive a reply, and that’s really concerning.” Cohen noted that one prior authorization request went unanswered for 83 days. More than 11,000 people in the U.S. turn 65 every day, and more than 70.5 million are enrolled in Medicare, according to the latest administrative data from CMS. A 65-year-old retiring in 2026 can expect to spend an average of $185,500 on healthcare and medical expenses throughout retirement, according to Fidelity Investments.
That figure is up 7.5% from a year ago amid rising prices for care, greater use of healthcare services as the population ages, and growing costs tied to managing chronic conditions. Meanwhile, there is a rising level of concern about the use of artificial intelligence in everyday life. It’s troubling that CMS knew about much of this and didn’t communicate it to the public,” Cohen said.
Under the program, which launched in January, prior authorizations for about 6.4 million Americans enrolled in traditional Medicare in New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington state are being carried out by AI. The WISeR model requires additional approvals for more than a dozen common medical procedures, such as epidural steroid injections for pain management, minimally invasive treatments for spinal stenosis in the back and osteoarthritis in the knees, and nerve-stimulation therapies for conditions such as sleep apnea and incontinence. Protecting beneficiary access to Medicare-covered, medically necessary care is a top priority.” “Some of the decision delays were quite long for patients,” said Gretchen Jacobson, vice president and Medicare expert at the Commonwealth Fund, adding: “You should think that new technology would make the process almost instantaneous.
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