AI Prior-Auth Pilot Delays
What happened
- A federal Medicare prior-authorization pilot in Washington state is accused of delaying care for seniors. - Critics say the WISeR program’s AI-driven reviews have led to slower approvals and care interruptions. - The controversy adds to clinician frustration as AI is already used to decide some Texas Medicare care. ( )
Why it matters
Washington state hospitals say a new Medicare pilot is making some seniors wait weeks longer for procedures that used to move faster. (statnews.com) The program is called Wasteful and Inappropriate Service Reduction, or WISeR. The Centers for Medicare & Medicaid Services launched it on Jan. 1, 2026, in six states — Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington — and it runs through Dec. 31, 2031. (cms.gov) WISeR adds prior authorization to selected Original Medicare services, meaning doctors or hospitals must get approval before treatment or face pre-payment review after the service. CMS says the model uses artificial intelligence and machine learning with human clinical review to speed decisions and cut fraud, waste, and abuse. (cms.gov; cms.gov) Sen. Maria Cantwell said on April 22 that Washington patients are now waiting four to eight weeks for some procedures, up from about two weeks before WISeR. STAT reported the figures came from a Cantwell office report using Washington State Hospital Association data. (statnews.com; publicnow.com) CMS says requests sent through a WISeR vendor portal are supposed to get a decision within 72 hours. But the agency also says requests sent through a Medicare administrative contractor instead of a vendor portal may take longer because they have to be forwarded back and forth. (cms.gov) That timing matters because the model started Jan. 1, 2026, vendor portals were to be operational by Jan. 5, and the prior-authorization requirement applied to dates of service on or after Jan. 15. CMS says providers can skip prior authorization, but then the claim goes to pre-payment medical review before Medicare pays it. (cms.gov; cms.gov) The services under review are a limited list, not all Medicare care. CMS says they include skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy for knee osteoarthritis, while emergency services and inpatient-only services are excluded. (cms.gov; asahq.org) Texas doctors are dealing with the same model now. The Austin Chronicle reported on April 23 that Texas Medicare patients seeking skin grafts, nerve stimulators, and other covered procedures have been subject to the AI-assisted review process since Jan. 15, and that Cohere Health is the WISeR participant for Texas. (austinchronicle.com; texmed.org) Provider groups have been warning for months that the model could slow care and add paperwork. The Washington State Hospital Association said private contractors would be allowed to use artificial intelligence and large language models to review and potentially deny coverage, while Texas physicians told the Chronicle many doctors still were not familiar with the submission portals. (wsha.org; austinchronicle.com) CMS has defended WISeR as a test aimed at unnecessary care and taxpayer spending. In its June 27, 2025 announcement, the agency said Medicare spent as much as $5.8 billion in 2022 on services with minimal benefit and said the model was designed to provide an “improved and expedited” review process. (cms.gov; cms.gov) The next fight is in Washington, not just hospitals. Cantwell pressed Health and Human Services Secretary Robert F. Kennedy Jr. about WISeR at a Senate Finance Committee hearing on April 22, as lawmakers and providers push CMS either to fix the delays or scrap the pilot. (finance.senate.gov; statnews.com)
Key numbers
- 1, 2026, in six states — Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington — and it runs through Dec.
- Maria Cantwell said on April 22 that Washington patients are now waiting four to eight weeks for some procedures, up from about two weeks before WISeR.
- (statnews.com; publicnow.com) CMS says requests sent through a WISeR vendor portal are supposed to get a decision within 72 hours.
- 1, 2026, vendor portals were to be operational by Jan.
What happens next
- But the agency also says requests sent through a Medicare administrative contractor instead of a vendor portal may take longer because they have to be forwarded back and forth.
- (austinchronicle.com; texmed.org) Provider groups have been warning for months that the model could slow care and add paperwork.
- (cms.gov; cms.gov) The next fight is in Washington, not just hospitals.
Quick answers
What happened in AI Prior-Auth Pilot Delays?
A federal Medicare prior-authorization pilot in Washington state is accused of delaying care for seniors. Critics say the WISeR program’s AI-driven reviews have led to slower approvals and care interruptions. The controversy adds to clinician frustration as AI is already used to decide some Texas Medicare care. ( )
Why does AI Prior-Auth Pilot Delays matter?
Washington state hospitals say a new Medicare pilot is making some seniors wait weeks longer for procedures that used to move faster. (statnews.com) The program is called Wasteful and Inappropriate Service Reduction, or WISeR. The Centers for Medicare & Medicaid Services launched it on Jan. 1, 2026, in six states — Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington — and it runs through Dec. 31, 2031. (cms.gov) WISeR adds prior authorization to selected Original Medicare services, meaning doctors or hospitals must get approval before treatment or face pre-payment review after the service. CMS says the model uses artificial intelligence and machine learning with human clinical review to speed decisions and cut fraud, waste, and abuse. (cms.gov; cms.gov) Sen. Maria Cantwell said on April 22 that Washington patients are now waiting four to eight weeks for some procedures, up from about two weeks before WISeR. STAT reported the figures came from a Cantwell office report using Washington State Hospital Association data. (statnews.com; publicnow.com) CMS says requests sent through a WISeR vendor portal are supposed to get a decision within 72 hours. But the agency also says requests sent through a Medicare administrative contractor instead of a vendor portal may take longer because they have to be forwarded back and forth. (cms.gov) That timing matters because the model started Jan. 1, 2026, vendor portals were to be operational by Jan. 5, and the prior-authorization requirement applied to dates of service on or after Jan. 15. CMS says providers can skip prior authorization, but then the claim goes to pre-payment medical review before Medicare pays it. (cms.gov; cms.gov) The services under review are a limited list, not all Medicare care. CMS says they include skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy for knee osteoarthritis, while emergency services and inpatient-only services are excluded. (cms.gov; asahq.org) Texas doctors are dealing with the same model now. The Austin Chronicle reported on April 23 that Texas Medicare patients seeking skin grafts, nerve stimulators, and other covered procedures have been subject to the AI-assisted review process since Jan. 15, and that Cohere Health is the WISeR participant for Texas. (austinchronicle.com; texmed.org) Provider groups have been warning for months that the model could slow care and add paperwork. The Washington State Hospital Association said private contractors would be allowed to use artificial intelligence and large language models to review and potentially deny coverage, while Texas physicians told the Chronicle many doctors still were not familiar with the submission portals. (wsha.org; austinchronicle.com) CMS has defended WISeR as a test aimed at unnecessary care and taxpayer spending. In its June 27, 2025 announcement, the agency said Medicare spent as much as $5.8 billion in 2022 on services with minimal benefit and said the model was designed to provide an “improved and expedited” review process. (cms.gov; cms.gov) The next fight is in Washington, not just hospitals. Cantwell pressed Health and Human Services Secretary Robert F. Kennedy Jr. about WISeR at a Senate Finance Committee hearing on April 22, as lawmakers and providers push CMS either to fix the delays or scrap the pilot. (finance.senate.gov; statnews.com)
