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<td><span style="font-family:Helvetica, sans-serif; font-size:20px;font-weight:bold;">Health Tech | Fierce Healthcare</span></td>
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<td><a href="https://www.fiercehealthcare.com/regulatory/ai-powered-prior-authorizations-medicare-have-greatly-delayed-care-wash-hospitals-say" style="font-family:Helvetica, sans-serif; letter-spacing:-1px;margin:0;padding:0 0 2px;font-weight: bold;font-size: 19px;line-height: 20px;color:#222;">WISeR Model greatly delaying care, WA hospitals report</a>
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<p><div class="col content" morss_own_score="5.191959798994975" morss_score="67.97727054464374">
<p>Early hospital data highlighted on Capitol Hill suggest that Medicare patients are waiting substantially longer to receive care due to a federal test program exploring automated evaluation of prior authorization claims in traditional Medicare. </p>
<p>The Wasteful and Inappropriate Service Reduction (“WISeR”) Model is a one-year, six-state pilot unveiled by the Centers for Medicare & Medicaid Services’ (CMS’) Innovation Center (CMMI) last summer and launched Jan. 1. </p>
<p>In line with the Trump administration’s push to weed out fraud, waste and abuse in Medicare, WISeR aims to use artificial intelligence to expedite prior authorizations for 13 medical services considered “low-value” or “vulnerable” to misuse, including skin and tissue substitutes. Beyond its technological components, the model is also a ramp-up of prior authorization in traditional Medicare, where it has so far not been widely used. </p>
<p>The approach—which has raised red flags among provider groups, <a href="https://www.fiercehealthcare.com/regulatory/ftc-secures-11th-hour-settlement-pe-firm-welsh-carson-over-alleged-roll-scheme">nonprofits</a> and <a href="https://www.fiercehealthcare.com/payers/payer-roundup-aoc-slams-cmmi-model-adding-prior-authorization-medicare-clover-health-creates">some lawmakers</a>—has received an initial poor review among Washington hospitals, per a report released this week by Senator Maria Cantwell (D-Wash.) based on data from 16 hospitals affiliated with the Washington State Hospital Association. </p>
<p>Topline, <a href="https://www.cantwell.senate.gov/imo/media/doc/wiser_snapshot_report1.pdf">the report (PDF)</a> flagged procedure completion times twice to four times as long as patients experienced prior to the model’s implementation “due to authorization delays.” For instance, procedures that were previously approved at the hospitals within “approximately” two weeks required four to eight weeks post-WISeR, according to the report, with patients “often rescheduled multiple times while awaiting authorization, causing prolonged pain and worsening underlying conditions.” </p>
<p>One organization highlighted in the report, the University of Washington Medical System, saw average approval times for its Urgent Authorizations (previously a single-day turnaround) and Standard Authorizations (previously three days) stretch to between 15-20 days after WISeR implementation. It also said it had nearly 100 patients waiting for one of the included procedures, epidural steroid pain injections, as a result of the model’s delays. </p>
<p>More than 18,600 Washington state residents received care services in 2024 through traditional Medicare that are now subject to prior authorization under the WISeR Model, according to the report. </p>
<p>Cantwell, who serves on the Senate Finance Committee, raised the findings Wednesday during a budgetary hearing with Health and Human Services Secretary Robert F. Kennedy Jr. She told him the treatment delays communicated by her constituents suggest that “AI is being used as a denial device for the CMS.” </p>
<p>“We have hospitals calling me about this, I have doctors calling me about this, I have patients calling me about this,” she told the secretary. “… To use AI as an app or a tool that might deny people and then cut them off from Medicare, when this part of Medicare was never a referral, is making me anxious that somebody really does think that AI should be used to judge our Medicare services.” </p>
<p>Kennedy said the delays described in the report are “unacceptable” and that his teams would work on ironing out what are “probably kinks in the system.” He defended the approach more broadly, saying that CMS was “being ripped off” on claims for the services selected in the pilot. </p>
<p>Cantwell, during Wednesday’s hearing, also touched on <a href="https://www.fiercehealthcare.com/regulatory/ftc-secures-11th-hour-settlement-pe-firm-welsh-carson-over-alleged-roll-scheme">transparency and outstanding questions</a> on how the AI tools used in the model are making their decisions. Kennedy responded that the program is “supposed to have a human supervisor” signing off on any claims identified for denial by AI. </p>
<p>Other issues flagged in the report were concerns among hospitals of increased administrative burdens and conflicts of interest due to the model’s structure, which has third-party administrators receiving a portion of the dollar value of any denied claims that aren’t later overturned. Such a structure could incentivize contractors to “weaponize AI-driven medical determinations … for the opportunity to maximize profitability.” </p>
<p>“Our patients are our top priority, and we are concerned that adding for-profit technology company layers between clinicians and care decisions can unintentionally create barriers for the people the system is meant to serve,” Tammy Buyok, president of MultiCare-owned Yakima Memorial Hospital, said in a quote included in the report. </p>
<p>The potential for extended delays, misaligned incentives and increased busywork were all among provider organizations’ chief rebuttals last year when weighing in on CMS’ plan to roll out the WISeR Model. </p>
<p>The <a href="https://www.aha.org/lettercomment/2025-10-23-aha-comments-cms-wiser-model">American Hospital Association</a>, for instance, pointed to “difficulties that our members have had with improperly administered prior authorization programs” outside of traditional Medicare and pushed for a delayed or more gradual rollout period. The <a href="https://www.ama-assn.org/health-care-advocacy/advocacy-update/july-11-2025-national-advocacy-update#:~:text=The%20AMA%20has%20serious%20concerns,future%20iterations)%20be%20truly%20voluntary.">American Medical Association</a>, last year in member advocacy messaging, said it was “especially concerned that this model could further expand prior authorization requirements into Traditional Medicare, by setting a precedent for mandatory programs in the future.”</p>
<p>Washington State Hospital Association President and CEO Cassie Sauer, in a new statement, applauded Cantwell for bringing her members’ experiences to Kennedy’s attention and said the group “strongly opposes the use of [AI] in Medicare when it interferes with patient care.” </p>
<p>CMS’ exploratory expansion of prior authorization in traditional Medicare comes as the practice faces widespread pushback from the public and, <a href="https://schrier.house.gov/media/in-the-news/democrats-introduce-legislation-block-wiseer-prior-authorization-model">by extension, lawmakers</a>. <a href="https://www.fiercehealthcare.com/payers/patients-cite-prior-authorization-biggest-healthcare-burden-kff">A KFF poll in January</a> found 32% of patients considered prior authorization a “major burden” when navigating their care, beating out understanding of their medical bills (23%) and scheduling appointments (20%). </p>
<p>Prior authorizations’ <a href="https://www.fiercehealthcare.com/providers/op-ed-prior-authorization-has-created-perception-problem-healthcare-industry">poor reputation</a> led the industry’s major insurers to <a href="https://www.fiercehealthcare.com/payers/insurers-have-eliminated-11-prior-authorizations-under-reform-pledge">pledge rollbacks on their use of the practice</a>—though <a href="https://www.fiercehealthcare.com/finance/despite-better-cash-flow-providers-missed-out-more-revenue-2025-due-increased-payer-denials">revenue cycle data</a> and <a href="https://www.fiercehealthcare.com/providers/community-health-systems-reports-low-volumes-earnings-dip-q1-2026">earnings commentary from provider organizations</a> suggest that denials are still having an impact. </p>
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<td><a href="https://www.fiercehealthcare.com/payers/unitedhealthcare-aetna-tout-progress-standardize-prior-authorization-part-industry-wide" style="font-family:Helvetica, sans-serif; letter-spacing:-1px;margin:0;padding:0 0 2px;font-weight: bold;font-size: 19px;line-height: 20px;color:#222;">Major health plans advance efforts to standardized prior auth</a>
<div style="font-family:Helvetica, sans-serif; text-align:left;color:#999;font-size:11px;font-weight:bold;line-height:15px;">Apr 24th 2026, 13:46</div>
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<p><div class="col content" morss_own_score="5.5856966707768185" morss_score="64.55846894800455">
<p>Major health insurers are advancing efforts to standardize prior authorization requirements as part of an effort to simplify paperwork for providers and reduce delays in medical care.</p>
<p>Two of the industry's leading organizations, AHIP and the Blue Cross Blue Shield Association, said Friday that leading health plans are making significant progress in their efforts to adopt a standardized approach for providers submitting electronic prior authorization requests for the majority of medical services.</p>
<p>The standardized approach will be used for medical services that are commonly subject to prior authorization, such as orthopedic surgeries and imaging services, including CT scans and MRIs, AHIP and BCBSA said. These services span commercial coverage, Medicare Advantage and Medicaid managed care. Additional services will be added over time. </p>
<p>This initiative is part of an <a href="https://www.fiercehealthcare.com/payers/insurers-pledge-smooth-out-prior-authorization-process">industry-wide commitment</a> announced last summer to smooth out the prior auth process and also improve transparency and communication around determinations. As part of that commitment, in alignment with the Department of Health and Human Services and the Centers for Medicare & Medicaid Services, insurers said they would demonstrate notable progress toward the goals by the beginning of 2026. About 50 plans signed on to the initiative, including all six of the largest, publicly traded insurance conglomerates: Elevance Health, Centene, Cigna, CVS Health's Aetna, Humana and UnitedHealthcare.</p>
<p>Key changes included reducing the number of services subject to prior authorization, as well as implementing solutions to promote electronic prior auth, with plans to establish a framework for both payers and providers by Jan. 1, 2027.</p>
<p>So far, leading health plans reduced prior authorizations for an array of services by 11% in the roughly nine months since the pledge was made. This equates to 6.5 million fewer prior auth requests for patients, AHIP and BCBSA <a href="https://www.fiercehealthcare.com/payers/insurers-have-eliminated-11-prior-authorizations-under-reform-pledge">reported</a> earlier this month. Reductions in Medicare Advantage specifically were 15%, according to the groups' report.</p>
<p>“As more providers adopt electronic prior authorization, this standardized approach will mean faster answers for patients, a more consistent experience for providers and less friction for everyone,” Mike Tuffin, AHIP President and CEO, said in a statement.</p>
<p>UnitedHealthcare, the insurance arm of UnitedHealth Group, said it has standardized the documentation process for more than half of its prior authorization volume with plans to have 70% of prior auth requests as part of this standardization process by the end of this year. </p>
<p>“Today’s announcement is another step in our work to modernize health care, making prior authorization quicker, simpler and more efficient,” said Tim Noel, CEO of UnitedHealthcare, in a statement. “These changes help care providers and patients save time and money and set the stage for a more seamless electronic experience, and our work will continue as we pursue a modern, touchless authorization process.”</p>
<p>Aetna said it has standardized 88% of its prior authorization volume, touting that it maintains the "fewest medical services requiring prior authorization among national health plans."</p>
<p>“Aetna is proud to lead, and most importantly, to deliver better, faster care to people who need it,” said Aetna President Steve Nelson in a statement. “Prior authorization should enable care, not delay it. We’re modernizing the process with speed, transparency, and clinical judgment to benefit everyone we serve.”</p>
<p>The health insurer said its efforts have resulted in more than 95% of eligible prior authorizations approved within 24 hours, 83% processed in real time, exceeding AHIP’s 2027 industry commitment of 80% and more than 1 million provider calls eliminated through automation and digital tools.</p>
<p>Aetna also noted its efforts to integrate medical and pharmacy decisions into single, condition-specific reviews and newly launch bundled prior authorization programs, including a comprehensive musculoskeletal offering, that build on earlier cancer bundles.</p>
<p>The Cigna Group said it expects to standardize more than 70% of its prior authorization volume for medical services by the end of 2026, with additional services added on a rolling basis. The health plan said its already reduced volume of medical prior authorizations by about 15%.</p>
<p>“We want patients to get the care they need when they need it, and we want doctors and their teams to be able to focus on patients – not paperwork,” Amy Flaster, M.D., chief medical officer at the The Cigna Group, said in a statement. “We are leading much-needed improvements to make prior authorization clearer and more consistent. While this is important progress, we know there’s more to do as we continue our journey to deliver a simpler, more personalized health care experience to all those we serve.”</p>
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<p><strong>Forwarded by:<br />
Michael Reeder LCPC<br />
Baltimore, MD</strong></p>
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