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A new bill from Democratic lawmakers seeks to repeal a controversial bill from the Centers for Medicare and Medicaid Services that would put artificial intelligence at the forefront of medical decision-making.
WHY IT MATTERS
The new Seniors Deserve SMARTER Care Act of 2025 – it stands for Streamlined Medical Approvals for Timely, Efficient Recovery – aims to reverse a U.S. Health and Human Services notice, published in July.
Under that CMS program, known as the Wasteful and Inappropriate Service Reduction (WISeR) model, providers in six states – New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington – are to be subject to Medicare claims reviews that use artificial intelligence and machine learning for prior authorization of certain services that HHS says are vulnerable to fraud and inappropriate use.
But the Democratic lawmakers proposing repeal of the measure strongly oppose the use of AI, which they say could be used by incentivized private organizations to make medical treatment decisions – and potentially deny care.
They say it could lead to potentially life-threatening outcomes for seniors in traditional Medicare and exacerbate provider administrative burdens.
The new CMS model aims to test enhanced technologies to improve and expedite the prior authorization process over six years beginning in January.
But lawmakers are concerned that automated and AI-driven denials will override the medical decisions of physicians in those six states, putting a cost-cutting algorithm in charge of critical healthcare choices and delaying needed care for their patients.
"We know that prior authorization in Medicare Advantage and elsewhere ultimately limits access to care, increases the burden on loved ones and care providers and leads to worse health outcomes," said Rep. Suzan DelBene, D-Wash., said in a joint statement with the co-sponsoring lawmakers.
The members of Congress said that while WISeR is intended to curb unnecessary spending, it could become harmful red tape, barring medically necessary care and adding to Medicare providers' administrative burdens.
"The administration has publicly admitted that prior authorization is harmful, yet it is moving forward with this misguided effort that would make seniors navigate more red tape to get the care they’re entitled to," said DelBene. "Congress needs to step in and protect seniors, their families and healthcare workers by stopping this model."
For those with progressing conditions, WISeR delays could lead to patients abandoning recommended treatment plans, hospitalizations or life-threatening events that would ultimately require more expensive interventions later as their health conditions worsen while waiting.
"It is not an exaggeration to say that the requirement of prior authorization for traditional Medicare services will kill seniors," said Rep. Mark Pocan, D-Wis.
"As a physician, I know that healthcare decisions should be made by patients and doctors, not insurance companies," added Rep. Dr. Kim Schrier, D-Wash. "Time and time again, we've seen how prior authorization has led to dangerous delays in care and undermined overall patient health."
In programs like Medicare Advantage, requests that are initially denied are ultimately approved on appeal, indicating that the initial denial process may be flawed or overly restrictive, the lawmakers argued.
In some cases, as with the class action claim against UnitedHealth two years ago, denials based on AI algorithms have led to lawsuits.
The lawmakers also questioned whether the WISeR model will make it difficult for providers and patients to understand why a denial is issued and how to appeal it.
"The use of AI in determining whether or not treatment is necessary is extremely reckless," said Pocan. "Unlike Medicare Advantage plans that already use AI in prior authorization decisions, traditional Medicare is supposed to cover you, no questions asked. This is a disastrous idea of epic proportions and should be immediately rescinded."
Under the WISeR model, private companies in each state will automate the reviews and will be paid in shares of "averted expenditures," creating a financial incentive to deny care, the bill sponsors said.
"The proposed repeal of the WISeR model underscores an important policy discussion about balancing innovation, oversight and patient access in healthcare," Jeff Ladner, chief product officer at GRC software vendor Onspring, told Healthcare IT News by email on Monday. We reached out to Ladner again after interviewing him earlier this month about how the rule would affect providers.
"Regardless of the legislative outcome, the debate reinforces the need for strong governance frameworks to ensure that technology, including AI, supports ethical and transparent care decisions."
THE LARGER TREND
With a history of wasteful healthcare spending in the United States, the health department is eager to "root out waste in Original Medicare," said Dr. Mehmet Oz, CMS administrator, when the agency announced the WISeR model earlier this year.
"Combining the speed of technology and the experienced clinicians, this new model helps bring Medicare into the 21st century by testing a streamlined prior authorization process, while protecting Medicare beneficiaries from being given unnecessary and often costly procedures," said Oz.
While some health IT experts recommend that provider organizations deploy AI where it solves pain points for patients, such as in eliminating care delays, others caution providers to beware of the high stakes of healthcare AI and the imperatives of clinician oversight.
"For patients, AI agents are transforming the medication journey by acting as concierges that provide real-time updates on copays, prior authorization status and financial assistance options," Dr. Colin Banas, chief medical officer at DrFirst, told Healthcare IT News in March.
But above all, AI in healthcare requires clinical oversight, said Scott Anderson, director of member relations and the liaison for the section of pharmacy informatics and technology at the American Society of Health-System Pharmacists.
ON THE RECORD
"As a doctor and former chief medical officer of Sacramento County, I’ve seen how harmful prior authorization can be when it delays or denies necessary care for patients," said Rep. Dr. Ami Bera, D-Calif. The WISeR model "creates a dangerous incentive to put profits ahead of patients’ health."
"These decisions should be made by doctors, not by algorithms designed to cut costs," Bera said in the statement from the bill's sponsors. "We should be working to strengthen Medicare, not layering on more red tape that threatens access to timely, high-quality care."
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Andrea Fox is senior editor of Healthcare IT News.
Email: afox@himss.org
Healthcare IT News is a HIMSS Media publication.
