From Financialexpress · Dimple Singh · · 2m
US Medicare Tests AI to Review Care
AI system may deny medical coverage for older Americans under Medicare trial.
In brief
AI system may deny medical coverage for older Americans under Medicare trial. US Medicare's AI trial could delay or deny care for 1.1 million beneficiaries in six states by flagging unnecessary services. Originally reported by Financialexpress.
Quick answers
- What happens next?
- The programme runs through 2031 and could expand to additional services and states if it reduces waste without creating access problems.
- What is the key takeaway from US Medicare Tests AI to Review Care?
- US Medicare's AI trial could delay or deny care for 1.1 million beneficiaries in six states by flagging unnecessary services.
US Medicare launches AI trial
The US government started a major experiment with artificial intelligence in Medicare on January 1, 2026.
WISeR covers six states
The six-year programme covers Original Medicare beneficiaries in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington.
WISeR targets specific services
The model covers skin substitutes, electrical nerve stimulator implants and knee arthroscopy for knee osteoarthritis.
AI-assisted review process
Providers submit prior-authorization requests before services or undergo post-service pre-payment review using AI and machine learning.
Human oversight required
AI does not make final non-payment decisions; recommendations must come from licensed clinicians using evidence-based procedures.
CMS selects six vendors
Cohere Health - Texas, Genzeon - New Jersey, Humata Health - Oklahoma, Innovaccer - Ohio, Virtix Health - Washington, Zyter - Arizona.
Skin substitutes cost $10.3bn
Skin substitutes accounted for $10.3 billion, or 83%, of spending on services covered by WISeR in 2024.
Spending on skin substitutes rose
Average spending per skin substitute service increased from $2,300 in 2019 to $21,200 in 2024, an 820% increase.
1.1 million beneficiaries affected
About 1.1 million traditional Medicare beneficiaries nationwide received at least one WISeR service in 2024.
EFF reports delays
EFF found cases taking 83 days for decisions and providers reporting patients 'crying in pain' while waiting.
High denial rates
Two WISeR vendors denied 5,944 prior-authorization requests in the first three months of the programme.
Payment structure concerns
CMS pays vendors for denied requests, but payments do not apply to denials later overturned on appeal.
Innovaccer warned of issues
Innovaccer told CMS it had not had enough time for full end-to-end testing with providers before launch.
What happens next?
The programme runs through 2031 and could expand to additional services and states if it reduces waste without creating access problems.
The headline
US Medicare's AI trial could delay or deny care for 1.1 million beneficiaries in six states by flagging unnecessary services.
