Oct 5, 2025
AI is increasingly becoming a part of everyday life. But in the context of health care, that's not necessarily a good thing.
As NBC News reports, the Trump administration plans to introduce a new program in 2026 that uses AI to approve or deny care for Medicare enrollees. (1) The pilot program will roll out on Jan. 1 and is slated to run through 2031. During that time, Medicare patients, providers and facilities in Arizona, Ohio, Oklahoma, New Jersey, Texas and Washington will be impacted.
Advertisement
It's a system already employed in the private health insurance sector. And, while it could lead to big savings, it could also result in many older Americans being denied the care they need.
A program that could have very mixed results
Medicare enrollees — particularly those who have private Medicare Advantage plans — are generally familiar with the concept of prior authorization. What this means is that providers must get approval from a Medicare plan for certain types of treatments or diagnostic tests to be covered.
The purpose of prior authorization is to ensure that expensive care isn't given to patients needlessly. But many providers and Medicare enrollees consider the prior authorization requirement a barrier to getting care.
A recent Kaiser Family Foundation (KFF) survey found that 73% of people think delays and denials of treatment by health insurers are a major problem. (2) And a 2025 KFF report found that Medicare Advantage made almost 50 million prior authorization decisions in 2023 alone and that 99% of enrollees in an Advantage plan are generally subject to prior authorizations for at least some services. (3)
Additionally, the KFF found that in 2023, 6.4% of prior authorization requests were denied. That's a modest decrease from the 7.4% of denials that happened in 2022, but a notable percentage nonetheless. The fear is that the new pilot program, known as Wasteful and Inappropriate Service Reduction (WISeR), will result in an increase in denials.
The Centers for Medicare & Medicaid Services (CMS) claims that WISeR, using AI technology, "will help ensure people with Medicare receive the most appropriate care that supports the best health outcomes while decreasing costs and easing administrative burden on providers and suppliers who go through the prior authorization process." (4)
Advertisement
CMS also says that human clinical review will be a part of the process so that it's not just a computer making health care decisions. And certain services will not be subject to an AI assessment, including inpatient-only services, emergency care, or any other treatment that would pose a significant risk to a patient if delayed. (1)
Meanwhile, KFF reports CMS spokesperson Alexx Pons said that as part of the new program, vendors will be "prohibited from compensation arrangements tied to denial rates.” That way, there will not be any incentive to deny care that's medically appropriate. This addresses concerns by critics who say vendors can benefit financially when less care is provided. (5)
However, there is already concern that denials have increased. A 2025 American Medical Association survey found that 61% of physicians worry that their health plans' use of AI is leading to more prior authorization denials. (6) So all told, not only might the WISeR program delay or deny care for Medicare enrollees, but it might also make providers’ jobs more difficult.
Must Read
- Dave Ramsey warns nearly 50% of Americans are making 1 big Social Security mistake — are you doing the same?
- Thanks to Jeff Bezos, you can now become a landlord for as little as $100 — and no, you don't have to deal with tenants or fix freezers. Here's how
- Robert Kiyosaki says this 1 asset will surge 400% in a year and begs investors not to miss this ‘explosion’
Join 250,000+ readers and get Moneywise’s best stories and exclusive interviews first — clear insights curated and delivered weekly. Subscribe now.
How Medicare enrollees can protect themselves
Having care denied by your insurer can be a nightmare. If you're worried about being denied care as a Medicare enrollee, there are some steps you can take to protect yourself.
-
Stay up to date: First, follow the topic for updates on the pilot program (especially in your state) so you know what challenges other beneficiaries might be facing and how best avoid them.
-
Choose your plan carefully: If you’ve yet to sign up for a Medicare Advantage plan, check its rating. Medicare uses a star rating system to rank Advantage plans on different criteria, so you can see how satisfied enrollees generally are with their plans.
-
Read through your plan carefully: You can also check your Medicare Advantage plan's evidence of coverage, which offers details on what the plan covers and what costs you can realistically expect. (7) It can serve as a starting point, though it may not tell you how likely you are to be denied care yourself on a case by case basis.
-
Document everything: Another step you should always take is to get full documentation from your providers when you're dealing with a medical issue. And if you're denied treatment by your plan, demand an explanation so you can review it with your providers and determine your next best step. Having clarity under what criteria you were denied may help you frame your appeal.
-
Appeal: Medicare Advantage plans have an appeals process you can follow if you get a prior authorization request denied. Plans typically offer a 30-day window to respond with a pre-service appeal and 60 days to respond with a payment-related appeal. You can, in some cases, request an expedited decision within 72 hours. (8)
-
Speak to your plan admin directly: If your state belongs to a list of those covered by the new WISeR program, talk to your Medicare plan administrator and providers about your concerns. Ask your insurer what criteria will be used to make decisions on prior authorization requests so you know what to expect. Confirm everything you're told in writing.
-
Choose providers carefully: Lastly, seek out providers who are patient and thorough — ones who will fight for you in the event of a denial, as necessary.
Article sources
We rely only on vetted sources and credible third-party reporting. For details, see our editorial ethics and guidelines.
NBC News (1); Kaiser Family Foundation (2; 3; 5); CMS (4); AMA (6); Medicare (7; 8)
You May Also Like
- Turning 50 with $0 saved for retirement? Most people don’t realize they’re actually just entering their prime earning decade. Here are 6 ways to catch up fast
- Inside a $1B real estate fund offering access to thousands of income-producing rental properties — with flexible minimums starting at $10
- Vanguard’s outlook on U.S. stocks is raising alarm bells for retirees. Here’s why and how to protect yourself
- Here are 5 easy ways to own multiple properties like Bezos and Beyoncé. You can start with $10 (and no, you don’t have to manage a single thing)
Maurie Backman has been writing professionally for well over a decade. Since becoming a full-time writer, she's produced thousands of articles on topics ranging from Social Security to investing to real estate.
