Earlier this year, Joanne, a Medicare patient from Quilcene, Washington, went to her doctor for severe pain in her lower back, down her leg and on the top of her foot. An MRI showed that a herniated disc was pressing on her sciatic nerve. Joanne’s doctor prescribed an epidural steroid injection to help alleviate the pain. Before this year, getting that procedure done would have been quick and routine.
But in January, Medicare started a new pilot program in Washington and five other states: Arizona, New Jersey, Ohio, Oklahoma and Texas. This program, called the Wasteful and Inappropriate Service Reduction (WISeR) Model, allows for-profit companies to use artificial intelligence to review and deny Medicare claims. In just the first few months, the number of stories like Joanne’s, in which care is delayed or denied, have exploded across these six states. Joanne’s doctor recommended this injection more than six weeks ago and it still hasn’t been approved. For over a month, she has had to use crutches or a wheelchair, worsening the arthritis in her hands, knees and ankles and adding to her chronic pain. Joanne is now looking to see if she can pay out of pocket for the procedure because, as she told my office, she “can’t keep living like this.”
So far, it appears that using AI to speed up claims review has resulted in rapid treatment denials and frustration for patients and providers alike.
WISeR isn’t just making it harder for seniors to get the care their doctors prescribe. It also opens the door to something more troubling. Under WISeR, outside companies are paid a share of the costs they “save” by rejecting claims. This creates a pervasive incentive to deny care. By injecting private companies into traditional Medicare with the goal of limiting care, the Trump administration is testing a new avenue to privatize the program. Congress must recognize and reject this Trojan horse before it fundamentally reshapes Medicare as we know it.
So far, it appears that using AI to speed up claims review has resulted in rapid treatment denials and frustration for patients and providers alike. Months in, doctor’s offices are still in the dark about basic functions of the program, and the Department of Health and Human Services hasn’t provided answers to foundational concerns since WISeR was announced last June.
The practice of requiring procedures to be preapproved, known as prior authorization, is extremely rare in traditional Medicare but already widespread in employer-sponsored health plans and privately run Medicare Advantage plans. Under this deeply flawed process, patients and doctors routinely spend hours fighting on the phone for approval of basic care. Many seniors choose traditional Medicare precisely so they don’t have to deal with this red tape. By injecting prior authorization into traditional Medicare, the differences between it and private Medicare Advantage grow slimmer.
Worse, prior authorization often doesn’t work. Over 4 million prior authorization requests made for Medicare Advantage enrollees were denied in 2024. Eighty percent of the denials were overturned when patients appealed the initial denial, but because appeals denials require considerable time, knowledge and energy, few patients contest coverage decisions.
Even if a denial is reversed, the delay in care frequently leads to more serious health issues and higher long‑term costs. Nearly a third of physicians say that a prior authorization requirement has led to a serious adverse health event for one of their patients. The American Medical Association has said these worse health conditions resulting from delayed care “may actually add significant costs to the nation’s health system.”
Kennedy and HHS seem more focused on enriching private companies with tax dollars that should be going to care for seniors.
Even HHS Secretary Robert F. Kennedy Jr. seemed to acknowledge the problem, saying in June, “Americans shouldn’t have to negotiate with their insurer to get the care they need.” But four days later, HHS announced WISeR.
As Kennedy prepares to testify before the House Ways and Means Committee this week, he should be ready to explain why his department is moving forward with WISeR despite widespread concerns that it delays care and opens the door to privatizing Medicare.
The administration claims that this program is supposed to test new ways to use technology to fight fraud in Medicare. We must develop more ways to detect, stop and hold bad actors accountable, but WISeR simply repeats the same flawed tactics that already delay care, frustrate patients and cost us more money. Kennedy and HHS seem more focused on enriching private companies with tax dollars that should be going to care for seniors.
Congress cannot sit on the sidelines while our constituents linger in pain. I’ve introduced legislation that would stop this program and other AI pilot programs like it. The House should quickly move it forward. This isn’t a partisan issue. Stories like Joanne’s could happen anywhere, from the reddest areas in Texas all the way to the bluest corners of Washington. We need to stand up for our seniors and stop this attempt to privatize Medicare.
Rep. Suzan DelBene
Suzan DelBene represents Washington’s 1st Congressional District in the House of Representatives.