Washington state Medicare users could soon have claims denied by AI
3 days ago
- #Medicare
- #AI in healthcare
- #prior authorization
- Starting Jan. 1, traditional Medicare recipients in Washington state will need prior authorization for certain outpatient procedures deemed 'low-value services'.
- A federal pilot program called Wasteful and Inappropriate Service Reduction aims to reduce fraud and waste by using AI tools to determine coverage eligibility.
- Private AI companies hired by CMS will be compensated based on the savings from denied claims, raising concerns about conflicts of interest.
- Critics argue the program is a step toward privatizing Medicare and could lead to unnecessary denials and bureaucratic hurdles for seniors.
- Democratic lawmakers, including Sen. Patty Murray and Rep. Suzan DelBene, oppose the program and have introduced legislation to repeal it.
- Prior authorization in Medicare Advantage has led to high denial rates, with most patients abandoning treatment when claims are denied.
- CMS claims the program will improve speed and accuracy, with final decisions made by clinicians, not AI, but transparency concerns remain.
- Medical associations in all six pilot states warn the program could delay care, reduce access, and increase burdens on patients and doctors.
- Dr. Bindu Nayak of the Washington State Medical Association highlights the risks of AI-driven denials worsening physician shortages and patient care delays.