Prior authorization, a process used by health insurers to determine if a medical treatment is necessary, has long been a source of frustration for patients and physicians. According to the source, the process often leads to delays and denials, with 41 percent of patients who experienced a denial reporting their care was delayed, and more than a quarter saying their health worsened as a result. The use of AI in this process is being explored as a potential solution to expedite approvals and reduce administrative burdens. However, the technology is not without its challenges and controversies. AI-driven prior authorization is facing resistance, as it may increase wrongful denials of health insurance coverage. A 2025 American Medical Association survey of physicians revealed significant concern about the application of AI tools, with 61 percent of doctors worrying that AI will exacerbate denials of what they deem are necessary treatments. The AMA advocates requiring insurers to provide detailed clinical reasoning to justify denials of coverage, in addition to more transparency regarding AI algorithms. In an email to Undark, health policy analyst Camm Epstein wrote that “AI should be used to make appropriate care easier to approve, not necessary care easier to deny.”
The Trump administration is currently piloting a program in six states, using AI to reduce unnecessary medical spending. This initiative, known as WISeR, or Wasteful and Inappropriate Service Reduction Model, is designed to reduce waste and fraud in original Medicare by using AI to evaluate services CMS believes may be vulnerable to overuse, fraud, and abuse. The project runs through December 2031 in six states, and combines technologies such as machine learning with human clinical review. However, critics have raised concerns about the model's impact on patient access. Before WISeR was implemented, Wendell Potter, an advocate for health insurance reform and former executive at health insurer Cigna, covered the political pushback against the model on the Substack publication “HEALTH CARE un-covered.” In the same publication, Zena Wolf, a researcher with the Center for Health & Democracy, cited investigations by the Washington Post, KFF Health News, and the Seattle Times that suggest in the first few months of the year, the model has caused delays in care and denials in some instances in each of the six states where it is being piloted.
The government and private insurers have tried to make improvements. A rule issued by former President Joe Biden’s administration in 2024, for example, included reforms designed to reduce delays for patients with government-run plans while streamlining the prior authorization process for physicians. It required insurers to make certain prior authorization decisions within 72 hours for urgent requests, and seven calendar days for non-urgent requests. Per Jan. 1 of this year, these timeline requirements went into effect for most health plans in the public sector. Last year, together with insurers, the Trump administration pledged to further streamline and accelerate prior authorization processes. Private insurance companies vowed to standardize electronic requests by 2027 and to “reduce the volume of medical services subject to prior authorization” by 2026, including for common procedures like colonoscopies and cataract surgeries.
Source: arstechnica
