Congressional Democrats try to force a vote to end Medicare AI prior authorization pilot

On Wednesday, Senate and House Democrats unveiled resolutions aimed at terminating a Medicare pilot program that employs artificial intelligence for the approval or denial of healthcare services. This technology-driven initiative has faced criticism for allegedly delaying care for elderly patients in at least one of the six states where it is currently active.

This latest attempt to prompt a vote to halt the program follows a recent ruling by the Government Accountability Office (GAO). The GAO concluded that the Wasteful and Inappropriate Service Reduction program (WISeR) necessitates Congressional approval and should have been presented to Congress before its implementation in January.

"Americans are sick and tired of abusive prior authorization tactics putting needed health care out of reach," stated Senate Finance Committee ranking member Ron Wyden (D-Ore.). "The last thing seniors need is even more AI denying the care they need."

Wyden, along with Senators Patty Murray (D-Wash.), Maria Cantwell (D-Wash.), Richard Blumenthal (D-Conn.), and Kirsten Gillibrand (D-N.Y.), sponsored the resolution to invoke the Congressional Review Act. The coalition of 20 Senate Democrats supporting the resolution reflects a growing opposition to the program, extending beyond the six states it is already implemented in: Arizona, New Jersey, Oklahoma, Ohio, Texas, and Washington.

In parallel, Representatives Suzan DelBene (D-Wash.) and Greg Landsman (D-Ohio) introduced a similar resolution in the House. This initiative follows DelBene's previous effort last year, which aimed to terminate the Medicare pilot program and was accompanied by a comparable bill in the Senate.

"WISeR is a dangerous program that is denying care to Medicare patients so companies can profit," remarked DelBene. "This program implements the same flawed prior authorization scheme from Medicare Advantage into traditional Medicare. If scaled up, it would serve as a backdoor to privatizing Medicare. It is causing needless delays, exacerbating health conditions, and resulting in increased costs over time. Congress must take action to end WISeR."

WISeR Program Details

In April, Senator Cantwell reported that seniors in Washington have encountered delays in receiving care due to the program. During a congressional hearing, she described the Centers for Medicare and Medicaid Services (CMS) as utilizing artificial intelligence as a "denial device."

The WISeR program focuses on a specific set of supplies and procedures that CMS associates with fraud. Notably, inpatient-only services, emergency services, and treatments that could pose significant risks to patients if delayed are excluded from this program. Healthcare providers are required to submit these supplies and procedures to designated WISeR contractors, who leverage technologies like AI to approve or deny care. These contractors are compensated according to a non-disclosed formula that includes the number of procedures they deny. This has led experts to express concerns about the program encouraging the denial of care.

DelBene has expressed apprehension regarding this payment structure to CMS Administrator Mehmet Oz, who recently stated in a letter that the agency intends to audit participants to ensure their decisions align with existing Medicare coverage criteria. He further indicated that vendors exhibiting a high rate of inaccuracies would be terminated from the program.

In response to the GAO ruling, a CMS spokesperson conveyed to STAT that WISeR "remains an active Innovation Center model, and CMS will continue to review the opinion and assess any appropriate next steps consistent with applicable law and administrative processes."

Congressional Review Act Process

The Congressional Review Act (CRA) provides a mechanism for Congress to overturn previously established rules promulgated by federal agencies. Although over 250 rules have been challenged under this provision, only a limited number have been successfully revoked—most notably, 16 rules from the Obama administration that were repealed at the start of the Trump administration.

To advance the resolution out of committee and to the Senate floor for a simple majority vote, it requires the signatures of 30 senators. The level of bipartisan support for this initiative remains uncertain; however, should the resolution pass both chambers, the WISeR pilot program would be rendered immediately ineffective.