Medicare Is Using AI to Fight Fraud, but Some Patients Say It’s Delaying Their Care

Artificial intelligence is becoming a bigger part of healthcare, including the way Medicare reviews medical treatments. A new pilot program is designed to reduce fraud and unnecessary procedures, but many patients and healthcare providers say it has also introduced new obstacles that can slow access to care.

Rural Patients Face Unexpected Extra Trips

For years, 65-year-old Bill Curry has driven about two and a half hours from his Oklahoma ranch to Oklahoma City every few months for a spinal epidural that helps manage chronic back pain. This year, however, the routine changed. Instead of making a single visit for treatment, he found himself traveling multiple times because of new Medicare approval requirements.

New Approval Rules Change a Familiar Process

During a visit in February, Curry was informed that his procedure now required advance approval before it could be performed. After returning weeks later for the injection, his clinic requested another appointment, something that had never happened before. The additional visit was meant to complete paperwork about his condition, leading Curry to question whether another lengthy drive was worthwhile.

Medicare Launches a New Pilot Program

The changes began in January when Oklahoma joined Arizona, New Jersey, Ohio, Texas, and Washington in a Medicare pilot project. The initiative introduces prior authorization into traditional Medicare, requiring approval before certain treatments, tests, or prescriptions can move forward. This marks a significant shift for a program that had generally avoided using this process.

Why Medicare Introduced Prior Authorization

Federal officials say the goal is to reduce fraudulent claims, prevent misuse of medical services, and limit unnecessary procedures that could expose patients to avoidable risks. By reviewing selected treatments before they are performed, Medicare hopes to improve oversight while lowering healthcare spending.

AI Powers the WISeR Initiative

The pilot program relies on artificial intelligence through a system known as the Wasteful and Inappropriate Service Reduction Model, or WISeR. The technology is designed to help identify claims that may require closer review, allowing Medicare to focus its resources on services considered more likely to involve improper billing or excessive use.

Certain Medical Services Receive Extra Review

The program currently applies to 13 healthcare services that federal officials consider more vulnerable to fraud or overuse. Epidural spinal injections, including the treatment Curry receives for his back pain, are among the procedures that now require additional approval before patients can receive care.

Patients Report Delays and Confusion

As the pilot program rolls out, many patients have described unexpected complications. Healthcare providers and Medicare beneficiaries in participating states report confusion about the new requirements, longer waiting periods, and uncertainty about when treatments will be approved.

Doctors Say Administrative Work Has Increased

Medical professionals involved in the program say the new approval process has created more paperwork and additional administrative responsibilities. Some providers believe these requirements consume valuable time that could otherwise be spent caring for patients, while also making scheduling more difficult.

Critics Compare the System to Private Insurance

Some healthcare workers argue that the pilot has introduced the same bureaucratic hurdles commonly associated with private insurance plans. They say traditional Medicare has historically offered more straightforward access to treatment, and they worry the new process could reduce that advantage for people living in the six participating states.

Early Results Raise Questions About the Program

Although Medicare hopes the AI-powered WISeR model will reduce waste and improve oversight, its early implementation has received mixed feedback. Reports from patients, physicians, and healthcare professionals suggest the system has experienced operational challenges, raising ongoing questions about whether the program can balance fraud prevention with timely access to medical care.