Medicare Tests AI Prior Authorization in Six States

The Centers for Medicare & Medicaid Services (CMS) launched the WISeR Model in January, short for Wasteful and Inappropriate Service Reduction Model, with the aim of “decreasing costs and easing administrative burden on providers and suppliers,” according to the CMS.

The program deploys AI-assisted prior authorization in traditional Medicare for the first time and requires physicians in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington to seek advance approval for a targeted set of procedures. Third-party tech companies contracted by CMS use AI to review those requests and issue initial decisions; a licensed clinician must sign off before any request is formally denied, CMS said.

Traditional Medicare has largely operated without prior authorization, leaving certain procedures vulnerable to overuse and fraud. WISeR tests whether AI can close that gap faster and more consistently than manual review, while keeping care delivery intact.

WISeR Approval Rates: 62% in Texas on First Submission, Rising to 84% After Review

In Texas, roughly 62% of requests receive approval on the first submission, rising to 84% after physician review at Cohere Health, the tech vendor running that state’s program, Washington Post Intelligence reported. Brian Covino, chief medical officer at Cohere Health, told Washington Post Intelligence that most approved requests receive a same-day response. For comparison, KFF (formerly Kaiser Family Foundation) found that more than 92% of prior authorization requests in Medicare Advantage were partially or fully approved nationwide in 2024.

The gap reflects where the program is in its rollout.

“We would expect to see, particularly at the outset of the model, some variation from what you observe in Medicare Advantage,” Abe Sutton, director of the CMS Innovation Center, told Washington Post Intelligence. Covino added that as physicians grow more familiar with documentation requirements, approval rates are expected to improve.

The added step has created real-world friction for patients accustomed to no pre-approval requirements. CBS News reported Tuesday (June 23) that an Oklahoma patient made two drives totaling 10 hours for a spinal epidural that previously required no advance approval, after the procedure was flagged for review under the new program.

Ohio Portal Failures and Arizona Billing Mismatches Are Causing Delays—Not the AI

Some delays trace to technical problems rather than the AI model itself. Ohio physicians reported that the Innovaccer portal was not fully functional for weeks, pushing approval timelines beyond the program’s three-day target for non-urgent care, according to Washington Post Intelligence.

A billing mismatch created payment delays in Arizona. Physicians who received authorization from tech vendor Zyter were subsequently denied payment because Medicare requires a unique tracking number that is often not assigned until days after authorization is granted, Washington Post Intelligence reported.

Gold Card Exemption Starts in July—If You Qualify

Federal officials have been direct about the program’s intent. “To pay for care that isn’t clinically appropriate is just not something we should accept as Americans,” Sutton told Washington Post Intelligence. CMS spokesperson Chris Krepich said all AI decisions are subject to clinician oversight and that poor vendor performance will trigger corrective action.

Starting in July, CMS plans to introduce a gold card exemption, letting physicians whose services are authorized at least 90% of the time skip the pre-submission process entirely, according to Washington Post Intelligence.

The Center for Medicare Advocacy, a nonprofit advocacy organization, flagged concerns in March about the vendor payment structure, which ties compensation partly to savings from blocking services. CMS said vendor payments are also adjusted for accuracy and quality metrics. WISeR runs through 2031 across the six states, covering an estimated 207,500 beneficiaries in its first year, according to KFF.