Additionally, providers who participated in the WISeR model, who were contracted to perform AI-powered prior authorization, earn a share of what CMS calls “avoided expenses.” This could mean income from rejecting requests for care. In turn, this points to a broader discussion about long-standing concerns regarding the obtaining of benefits on the basis of discouraging that patients obtain medically necessary care. Several legislators have inserted resolutions and amendments to block funding for the WISeR model, citing threats to patient access.
However, the Trump administration appears to be two minds when it comes to prior authorization. As CMS expands its use in original Medicare using AI, the agency wants to reduce and optimize its use by private insurers, including Medicare Advantage plans. CMS Administrator Mehmet Oz warned insurance company executives that they must ease the burden of prior authorization, or the federal government will impose regulation: “If you don’t do it yourselves, we will do it for you,” he said. said National News Desk, a television news program.
Possibly to prevent further action by the executive branch or passage of laws by lawmakers, health plans recently released data suggesting they are meeting the administration’s demands. Industry survey reveals that between June 2025 and April 2026, prior authorization requests refused by 11 percent. Is a strangerHowever, if the denial rate has decreased.
Responding to an industry group survey Conducted last year, all responding health plans agreed with the statement: “AI or algorithms without review by a physician or professional are not used to deny prior authorization requests that involve medical necessity or clinical considerations.” Furthermore, insurers fiance more transparency around the clinical reasoning behind prior authorization.
This may alleviate some of the worry about the lack of human review of decisions made by AI. But it won’t be easy to appease the detractors.
Jared Dashevsky, doctor and founder of an educational and media platform called Healthcare meeting, wrote that AI could “remove barriers, reduce administrative waste, give us more time with patients. But that’s not what’s being built.” Instead, he says, there is an “arms race to deny and appeal faster. More automation of a broken system that should not exist in its current form.”
This article was originally published in dark. Read the original article.
