Ohio one of six states to test AI-led prior authorization for Medicare

Federal officials have named Ohio as one of six states to test the use of AI to determine whether Medicare will pay for more than a dozen treatments, ranging from steroid injections for pain management to devices for controlling incontinence (Source: “Medicare to require prior authorization for some procedures in Ohio starting in 2026,” Columbus Dispatch, Sept. 18).

The six-year pilot program, which begins Jan. 1 and is called the Wasteful and Inappropriate Service Reduction Model (WISeR), aims to reduce overspending and fraud. CMS will begin using technology to determine whether Medicare should pay for a claim before treatment is provided. But a human clinician must review any denied claims, not AI alone, according to the Centers for Medicare & Medicaid Services.

The Centers for Medicare and Medicaid Services estimated that 25% of all health care spending in the United States is wasteful and could be cut without harming patients.

However, Democrats and doctors are wary of requiring pre-approval for certain medical conditions in traditional Medicare. Called "prior authorization," the process is more common in private insurance and can lead to delayed and denied care.

About 16% of Ohioans, or 2.5 million people, are enrolled in Medicare, the federal health insurance coverage for those over 65 years old and some younger adults with disabilities.