Trump Proposes Medicare Shift: Artificial Intelligence Determines Eligibility for Coverage or Exclusion
The Centers for Medicare and Medicaid Services (CMS) is set to launch a new pilot program next year, aiming to ensure people with Original Medicare receive safe, effective, and necessary care. The program, known as the Wasteful and Inappropriate Service Reduction (WISeR) Model, will utilise artificial intelligence (AI) software to expedite the prior authorization process for certain items and services in Original Medicare.
The WISeR Model will focus on items and services that are particularly vulnerable to fraud, waste, and abuse, or inappropriate use. It will be implemented in six different states, including Texas, Arizona, New Jersey, Ohio, Oklahoma, and Washington, starting from January 1, 2026.
The CMS is collaborating with private companies experienced in managing prior authorization processes for the WISeR Model. The press release does not specify the types of Medicare coverages that will be affected by the AI software, nor does it provide details on how the AI software will make its determinations.
However, concerns have been raised about the potential for the AI algorithms to deny claims, earning the WISeR Model the nickname of an "AI death panels" program. It is important to note that the CMS aims to safeguard federal taxpayer dollars and help patients and providers avoid unnecessary or inappropriate care.
The results of the pilot program are yet to be determined, as the CMS press release does not mention how they will be used. It is also unclear how the pilot program will be funded.
It is worth noting that algorithms of this sort have been subjected to litigation in the past, as reported by The New York Times. The potential financial incentive for the AI companies involved in the WISeR Model to deny claims is another concern.
The CMS press release about the new program has a tone similar to that of a DOGE meme, indicating a light-hearted approach to a potentially contentious issue. Despite this, the CMS is committed to improving the efficiency and effectiveness of the Medicare system, and the WISeR Model represents a significant step in that direction.
As the program progresses, it will be crucial to monitor its impact on patients, providers, and the overall Medicare system. Only time will tell whether the WISeR Model will live up to its promise of reducing wasteful and inappropriate services in Original Medicare.
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