CMS Launches Medicare Prior Authorization Pilot Using AI

The Centers for Medicare & Medicaid Services (CMS) has introduced the Wasteful and Inappropriate Service Reduction (WISeR) model, a new Innovation Center initiative aimed at reducing unnecessary services in traditional Medicare by streamlining the prior authorization process. WISeR will leverage advanced technologies such as AI and machine learning to expedite prior authorization decisions for select services vulnerable to fraud, waste, and inappropriate use, while ensuring that licensed clinicians retain final authority over coverage decisions. The model, running from 2026 to 2031, incentivizes participants based on their success in reducing unnecessary services, lowering Medicare spending, and improving provider and beneficiary experiences. This initiative comes amid broader prior authorization reforms to address the significant healthcare spending attributed to low-value services, which can harm patients and inflate costs. Physicians have expressed mixed feelings about prior authorization, acknowledging its intent to improve care but criticizing the administrative burden it imposes, with recent voluntary reforms aiming to simplify and speed up the process. CMS’s efforts reflect a commitment to modernizing Medicare's utilization management while protecting patient safety and reducing costs through technology-enabled, clinician-led review processes.