The US Centers for Medicare and Medicaid Services (CMS) is launching a pilot program to use AI for authorizing patient claims, aiming to reduce wasteful and inappropriate care. The AI-powered program, known as the Wasteful and Inappropriate Service Reduction (WISeR) Model, will assess the appropriateness of medical services for Original Medicare recipients in six states by 2026.
The AI algorithm will evaluate claims and determine coverage eligibility for specific procedures, such as spine surgeries and steroid injections. The system will focus on identifying expensive or potentially harmful practices and adjust the list of targeted procedures based on findings about overuse. Private companies will run the AI evaluations and will be financially incentivized to reduce unnecessary procedures by sharing in Medicare savings generated from denied claims.
However, there are concerns that the AI system may delay care and restrict necessary treatments, potentially harming patients. Providers worry that AI decisions may lack the nuance and empathy of human judgment, potentially leading to incorrect or unfair decisions. Furthermore, the financial incentives for companies running the AI evaluations may prioritize cost savings over patient care, potentially leading to denied claims and reduced access to necessary treatments.
While AI can bring benefits such as improved efficiency, enhanced accuracy, and cost savings, the potential risks and challenges associated with its use in authorizing patient claims need to be carefully considered. As the pilot program progresses, it will be essential to monitor its impact on patient care and ensure that the AI system is used in a way that prioritizes patient well-being and safety.
