Artificial Intelligence (AI) to be used to review Medicare outpatient procedures

The new Medicare prior authorization model, known as WISeR, will employ artificial intelligence to evaluate the eligibility of traditional Medicare enrollees for certain outpatient procedures. Covered procedures include those considered too costly compared to their medical benefits, such as impotence treatment and knee arthroscopy. Health care professionals will be responsible for reviewing any denials made by the AI technology. Dr. Matt Hollon from the Washington State Medical Association has expressed skepticism about this program, asserting that patient care should be directed by doctors rather than automated systems.

The third-party companies involved in this initiative will be compensated with a portion of the savings they create, raising concerns about potential incentives to deny approvals. As the healthcare landscape evolves, this model may significantly affect patient access to necessary treatments. Medicare’s shift to AI-driven decision-making highlights broader trends in healthcare administration. Stakeholders will need to monitor the impact of these changes on patient care and outcomes.