Medicare’s AI push snarls patients and doctors in errors and delays

Bill Curry, a 65-year-old cattle farmer from rural Oklahoma, has been dealing with back pain for years. To manage his pain, he has been making regular trips to Oklahoma City for epidural injections in his spine. However, this year, his routine has been disrupted due to a new Medicare program implemented in Oklahoma.

In January, Oklahoma became one of six states participating in a pilot program testing the use of preapprovals in traditional Medicare. This program, known as the Wasteful and Inappropriate Service Reduction Model (WISeR), aims to save money for the federal government and protect patients from potentially unnecessary care. Epidurals, like the ones Curry receives, are among the 13 medical services subject to this new program.

The rollout of WISeR has not been smooth, with patients, doctors, and healthcare professionals in Oklahoma and other pilot states reporting confusion, errors, long wait times, and stress. The program, powered by artificial intelligence, requires patients or their medical teams to seek insurance approval before certain procedures, tests, and prescriptions can proceed.

Despite CMS touting the efficiency of the process, participants have experienced delays and denials. Doctors and staff must submit medical records online for approval, with AI systems making quick decisions based on set criteria. However, some providers have raised concerns about AI-driven errors leading to incorrect denials.

The prior authorization process has also led to increased costs for the government, as more rejections result in more appeals being filed with Medicare’s administrative contractors. This in turn can cause delays in payment for healthcare providers, impacting their ability to provide care to patients in a timely manner.

While the goal of WISeR is to reduce inappropriate care without delaying necessary treatment, the implementation has faced criticism from both providers and patients. Some fear that if the pilot project is successful, prior authorization may be expanded to include more procedures, leading to increased red tape and costs for patients and doctors.

As CMS continues to assess the effectiveness of the WISeR program, stakeholders are encouraged to provide feedback on their experiences with prior authorization. The ultimate goal is to ensure that patients receive the care they need while reducing unnecessary spending and protecting against fraud and abuse in the healthcare system.