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.

[Ms. Toad]

25. Gotcha. You believe it is appropriate to force me to choose between

Living with a cancer that is doubling every 2-3 weeks while waiting months for an appeal to an AI denial of a skin graft - or paying for it out of pocket and fight an insurance appeal while I'm fighting for my life. Not a hypothetical. It's my life.

Thanks a bunch.

I chose standard Medicare because it left medical decisions to the doctor and the patient. If a doctor is making inappropriate decisions, Medicare can deny the claim after the fact - and the doctor (not the patient) incurs the cost of the appeal (both money and time). If that happens too many times, they will pay better attention to their decision-making.

Turning Medicare into Medicare Advantage on steroids (using AI to make the decisions) is not the solution to the fraud you believe is occurring.

[Silent Type]

26. How many of those services have anything to do with diagnosing or managing cancer? Plus,

if doc uses correct diagnosis — and AI checks with your claims history — it will likely be approved before you drive home. Even faster than your doctor who’ll fumble around with any odd change in therapy making sure they meet coverage guidelines.

Again, which one of those services do you think will be denied, especially if you have a history of cancer?

Hope you are doing well.

[Ms. Toad]

28. It was in my post - a skin graft.

As is typical with many extremely aggressive cancer, there is a two step procedure for surgery. The first leaves a large open wound, during a 2-3 week wait for detailed pathology - since many aggressive tumors require a 1-2 cm clean margin, and it takes time to do that detailed examination.

Doctors cover that wound with a graft to minimize the risks of living with an open wound. Once there is no risk that they need a second surgery, an allograft (self-graft) is used. But that creates a second, much larger, wound so they don't generally use an allograft for the initial surgery.

So doctors need to move immediately for the first surgery, without the need for any delay associated with pre-approval to remove the bulk of the tumor so it doesn't continue to double.

The general rule for pre-approval is a 10-day delay before a procedure will even be scheduled. (My surgery was scheduled for a week after diagnosis - and doctor was upset it was delayed that much.) My daughter uses $200,000 in medical care each and every year, with a number of procedures that require pre-authorization. (She requires an MRI every year, and she is currently battling over the medical portion of her infusion (following an initial battle over the pharmaceutical portion of the infusion). That battle has been going on for more than a month. I am very familiar with pre-approval and scheduling requirements. It doesn't happen on while you drive home basis.

Because of her conditions, I am also familiar with many circumstances in which conservative therapy is not appropriate. The medication (and related procedure) my daughter is battling over put her in remission, after two years with repeated hospitalizations. Because her Mayo score is currently zero, they contend she doesn't need the medication anymore - even though the only reason her Mayo score is zero rather than 9 (as it was for much is the two years) is because of the medication. Just over example of doctors treating patients knowing more than insurance companies or AI.

And I'm my car, a history of cancer does not guarantee that even human review won't result in a life-threatening delay. The graft. I received was denied, after the fact. Had pre-approval been required, I might not be here. It was ultimately approved, but it took a month or so

I am not intimately familiar with every procedure on the list - but the fact that I have direct experience with one - and with an inappropriate denial - (and far too intimately familiar with profit-motivated denials) suggests that others would fall into the Medicare Advantage on steroids sinkhole.

Again, the government has tools to address actual fraud. They should use them, rather than turning Medicare into Medicare Advantage on steroids. There's a reason Medicare Advantage has such a bad reputation.

I am currently fine, although I had a recurrence scare earlier this year and, ironically, the doctor was reluctant to order an MRI because of his experience with insurance and Medicare Advantage.

[Silent Type]

29. There is a new policy on skin substitutes that removes the incentive for doctors making thousands of dollars off

the 6-month float in pricing, a several billion dollar ripoff of highest proportions.

If your doc uses proper diagnoses codes, it won’t be a problem in your case. And even if it were denied pending additional info, your doc will send in supporting documentation, measurements, skin product, many send photos of wounds especially for exceptionally long treatment. It will be approved within hours.

Now, if you have wounds that don’t heal, or at least show signs of improvement/stabilization, that go on for years, doc will likely have to send in records.

Again, the new coverage policy where doc doesn’t get paid $5000 for a skin substitute that cost him/her $800, will eliminate 90% of claims even reviewed. Wouldn’t be surprised if those edits aren’t removed or restricted to certain diagnoses that exhibit strange utilization patterns.

[Ms. Toad]

31. Nonsense.

And even if it were denied pending additional info, your doc will send in supporting documentation, measurements, skin product, many send photos of wounds especially for exceptionally long treatment. It will be approved within hours.

The point is that ANY delay is life-threatening. And it is kind of impossible to send photos of a wound that does not yet exist. The point is that the surgery would be delayed until approval for all components - including the graft - are obtained.

And the suggestion that approval would be granted within hours is pure fantasy. I've successfully appealed dozens of denials. (I've only lost one, which I ultimately decided wasn't the worth the continued fight.) Not a single one was granted within hours (even if you don't count the days or more it took to notify me of the denial). The longest took 8 months and over 200 hours of my time. The shortest, I believe, took approximately 3 weeks.

The tinkering with the codes to minimize damage should take place before any pre-authorization for medical care (other than treatment which doubles as cosmetic care) is imposed, not after it is implemented - and the damage has already been done. Anyone implementing a new computer system knows you run parallel systems until the bugs are worked out - you don't implement an untested program in mission critical situations. And medical care is about as mission-critical as it can get. The same standards should apply.

[Silent Type]

33. None of those are life threatening conditions. Let's be honest here. No it's not fantasy that it will happen quickly

with AI. It will as long as doc's office has sense to review the coverage policy for bioengineered skin products and make sure the diagnoses codes match the covered diagnoses codes. It's that simple.

What bioengineered skin product do you think will be denied for someone with hard to heal wounds after cancer surgery?

The new coverage policy for bioengineered skin products will eliminate a high percentage of wound care expenditures that don't help patient and/or takes advantage of the reimbursement system.

Plus, do you even live in those 6 states?

[Ms. Toad]

34. And just now would you know "none of those were life threatening'

Since I didn't provide details. I'm fact, the one which took 8 months to resolve was limb threatening. Fortunately, because there was no front-and gate-keeping, the battle took place after the surgery had already saved my right arm.

Which is the point. The promise of Medicare is that I don't have to put up with front-end gate-keeping that might impose delays that put my health at risk. Certainly it is unconscionable to insert a glitchy AI decider with a profit motive/bias to deny claims.

And yes, I live in Ohio, and I resent being a subject of this experiment which puts my access to health care at risk.

[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.

[jls4561]

27. I love the name - WISeR. It's become a cliche to say that every pronouncement by this administration is Orwellian

double speak.

Why don’t they just call it DOGE is Everywhere, or DIE.

[UTUSN]

30. Crap

[rampartd]

32. who needs a "death panel?"

we'll just let some apartheid addled tech lord write code to kill us off.