This month Senate Republicans voted against an effort to rein in a controversial pilot program that introduces prior authorization in traditional Medicare using AI – a policy that will likely make seniors navigate additional administrative burdens to get approval for necessary medical care. 

As CEPR noted when the program was first rolled out, the Wasteful and Inappropriate Service Reduction (WISeR) model doubles down on prior authorization programs that are common in the privatized Medicare Advantage program, and which have attracted intense criticism for years. While basically non-existent in traditional Medicare, prior authorization is used by the private insurers that dominate the Medicare Advantage system – to the frustration of doctors and patients alike. A recent survey of physicians found the vast majority (93 percent)  believed that these policies delayed necessary care, and the added administrative burdens required to deal with insurance companies drive up health care costs.

A Senate investigation of prior authorization in Medicare Advantage found that leading insurance giants UnitedHealthcare, Humana and CVS had disproportionately denied prior authorization requests to cover post-acute care. Internal documents showed that the companies were using AI and machine learning tools to deny more claims – and thus increase profits.  The WISeR pilot programs in question – underway in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington – seem similarly designed to incentivize the denial of care. The federal government is essentially creating a program that rewards the companies running the pilots for denying coverage, since they will “receive a percentage of the savings associated with averted wasteful, inappropriate care as a result of their reviews.”

Though the Senate vote fell short, there are other efforts to monitor the WISeR pilot. A group of Democratic lawmakers sent a letter to CMS Administrator Mehmet Oz pushing for more information about the delays that doctors and patients are reporting in prior authorization decisions, and what metrics the administration will use to judge whether the program is a success. These inquiries come as reports suggest that the program is operating just as critics feared it would – particularly in the state of Washington, where patients are waiting for weeks for decisions that were supposed to happen in a matter of days. And the process of appealing adverse decisions is raising the overall costs of the program as well.

Just before the Senate vote, the Office of Inspector General at the Department of Health and Human Services just released two reports that back up the earlier Senate investigation of prior authorization in the Medicare Advantage program. Lawmakers would never admit that they want to actually expand this practice of denying health care to traditional Medicare, but the votes speak for themselves.