Medicare is experimenting with having AI review claims – a cost-saving measure that could risk denying needed care
Publish Date: 2026-02-04 08:32:00
Source Domain: theconversation.com
Medicare has launched a six-year pilot program that could eventually transform access to health care for some of the millions of people across the U.S. who rely on it for their health insurance coverage.
Traditional Medicare is a government-administered insurance plan for people over 65 or with disabilities. About half of the 67 million Americans insured through Medicare have this coverage. The rest have Medicare Advantage plans administered by private companies.
The pilot program, dubbed the Wasteful and Inappropriate Service Reduction Model, is an experimental program that began to affect people enrolled in traditional Medicare from six states in January 2026.
During this pilot, medical providers must apply for permission, or prior authorization, before giving 14 kinds of health procedures and devices. The program uses artificial intelligence software to identify treatment requests it deems unnecessary or harmful and denies them. This is similar to the way many Medicare Advantage plans work.
As health economists who have studied Medicare and the use of AI in prior authorization, we believe this pilot could save Medicare money, but it should be closely monitored to ensure that it does not harm the health of patients enrolled in the traditional Medicare program.
Prior authorization
The pilot marks a dramatic change.
Unlike other types of health insurance, including Medicare Advantage, traditional Medicare generally does not require health care providers to submit requests for Medicare to authorize the treatments they recommend to patients.
Requiring prior authorization for these procedures and devices could reduce wasteful spending and help patients by steering them away from unnecessary treatments. However, there is a risk that it could also delay or interfere with some necessary care and add to the paperwork providers must contend with.
Prior authorization is widely used by Medicare Advantage plans. Many insurance companies hire technology…
