For years, Americans have been caught in a destructive healthcare bind: they need vital medical procedures, but they must first navigate a bureaucratic minefield known as prior authorization. I felt the pain of this reality firsthand during my 19 years as an interventional radiologist at Mayo Clinic. Every Monday, I arrived at work confronted by a stack of manila folders filled with denied prior authorizations. My requests for the care my patients needed were routinely blocked, forcing my nurse — one of the very best I’ve ever worked with — to spend half her time on paperwork rather than hands-on patient care.
I was far from alone. The prior auth process has become infamous for delaying necessary care, creating mountains of paperwork for doctors and fueling allegations of inappropriate denials. What began as a measure introduced by insurers in the 1960s to reduce in-patient medical costs while promoting safe and efficient care, and which insurers maintain is a powerful tool to tackle the very real problem of fraud, waste and abuse (FWA), is now often seen as a colossal barrier to care. In the AMA’s 2024 prior authorization physician survey, a resounding 93% of physicians reported care delays due to prior auth, and more than a quarter (29%) said prior auth has led to a serious adverse event for a patient in their care.
A new balance is needed to bring rationality into care delivery while also addressing the pervasive problem of FWA in Medicare. Physicians and payers are unified in their alarm over FWA, a systemic problem with estimates suggesting that up to 42% of Medicare beneficiaries annually receive care that is essentially worthless.
Since its inception, AI in prior auth has only been at work in the commercial healthcare marketplace. Now new innovative approaches that reframe prior auth as a resource instead of a roadblock have come to Medicare via the WISeR model. The intention is to offer a path to cut through the red tape on both the provider and payer sides of health insurance while also tackling FWA. If they work, they’ll benefit patients, providers and the Medicare trust fund.
A new chapter for prior authorization
On January 1, WISeR launched a pilot program in six states (Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington) with the aim of streamlining prior authorization and reducing FWA (full disclosure: my company Humata manages Oklahoma’s WISeR requests). The pilot targets 17 procedures or items notorious for FWA, including knee arthroscopy, which has proven to have zero clinical benefit over placebo for many patients. Also on the list are skin substitutes, for which Medicare spending increased an incomprehensible 640% in just two years.
It’s also worth noting that WISeR isn’t without precedent in traditional Medicare. In 2020, CMS launched a nationwide prior authorization program for specific hospital outpatient procedures, including rhinoplasty and vein ablation, that were prone to improper billing, and has long required prior approval for high-cost durable medical equipment like power wheelchairs. WISeR builds on this foundation.
However, the program faced understandable criticism before it even started. Prior authorization is a controversial tool, and adding AI to Medicare’s complex structure is bound to raise eyebrows. Critics also point to a murky payment structure and concerns about AI overreach. And 61% of physicians are already concerned that use of AI for prior auth will lead to an increase in denials.
Despite this skepticism, WISeR offers a practical way to make prior authorization work faster, better and without the headaches that currently plague the process for patients and providers.
Among those pain points are the delays inherent in traditional prior auth, in which patients and providers routinely must wait up to 30 days to receive a determination. CMS is demanding that WISeR hold itself to higher standards. Because AI will automatically help physicians to submit the prior auth requests, and then assist Medicare in reviewing them based on existing coverage standards, all determinations under WISeR will be required much faster — in under three days, to be exact. The goal is to tackle FWA while simultaneously avoiding the pitfalls of outdated prior auth practices.
Eliminating the “black box” denial
The most urgent criticism centers on the use of artificial intelligence. Will the AI issue “black box” denials (denials that are vague, lack transparency and are rendered without rationale) leaving patients and providers confused and helpless?
Simply put, no. The industry must ensure that AI will not, and cannot issue black box denials by using technology that analyzes submitted authorizations based only on the existing CMS national and local coverage determinations. If the AI is unable to provide an immediate authorization approval, it automatically kicks the authorization to a human physician or nurse, who makes the ultimate decision. That way, the system accelerates the process of approval when the need for care is definitive and accurately documented instead of using an opaque mystery mechanism to evaluate care.
Incentivized for accuracy, not denial
Another fear is that WISeR participants are simply bringing the private sector’s worst habits to Medicare. The reality is far more nuanced.
Payment under WISeR is dependent on the WISeR participants’ ability to process authorizations correctly, in a streamlined fashion, and with appropriate clinical expertise. If necessary care is inappropriately denied, or the authorization process strays from established Medicare norms, prior auth tech platforms face financial clawbacks, a structure deliberately designed to align participant incentives with accurate, timely determinations rather than denials.
Ultimately, this technology has the power to save the American taxpayer billions of dollars in mitigated FWA without sacrificing quality.
A work in progress
WISeR is slated to run through 2031, so it is not just reasonable but essential that CMS remains agile through the next six years, embracing modifications as states and their healthtech partners learn together what truly works and what doesn’t. The goal goes beyond a successful pilot to building an economically sustainable and more patient-forward future for Medicare.
As WISeR matures, what will matter most is that CMS ensures the payment structures governing AI and technology partners are transparent, publicly reported and directly tied to patient outcomes as well as cost reduction. When Americans can clearly see how technology vendors are compensated and whether that compensation reflects genuine benefit to beneficiaries, the program earns the public trust it needs to succeed and scale.
Huge challenge, enormous opportunity
For too long, the prior authorization process has been broken while FWA has become a threat to the long-term survival of Medicare. We can’t know today if WISeR is the perfect solution. If the program proves that AI can cut costs while upholding the standard of care and drastically improving efficiency, it will set the stage for a much-needed, industry-wide revolution in both the public and private healthcare prior authorization space.
With WISeR, the industry has the technology, the incentives and the opportunity to prove we have a ready fix. As someone who has seen both the failures of the current system and the promise of what comes next, I believe we cannot let skepticism or fear prevent us from testing a solution that could benefit every American patient and provider. Instead, we must give this program a fighting chance to succeed. Technology may not be the cure for all of our healthcare system’s ills. But when used properly and with honorable intentions, it has the power to transform a stagnant system and to change — even save — lives.
Author bio:
Dr. Jeremy Friese is a transformative force at the intersection of healthcare delivery, AI innovation, and payer strategy. As the Founder, Chairman, and CEO of Humata Health, he leads the development of advanced AI solutions that streamline prior authorization — addressing one of healthcare’s most challenging friction points for providers, payers, and patients alike.
Editor’s note: The author’s company was part of a competitive bidding process for the Oklahoman WISeR pilot
Photo: Piotrekswat, Getty Images
