Five months into a pilot program that uses AI to review certain Medicare procedure requests, Washington seniors face new hurdles and worsening health outcomes, according to health care providers and lawmakers.

The program, which incentivizes participating private companies to deny procedures, has become the target of a repeal effort by Democratic Congressional members, including those from Washington state.

The six-year federal Wasteful and Inappropriate Service Reduction program (WISeR), which launched in Washington and five other states in January, aims to reduce fraud and waste by requiring prior authorization for procedures deemed “low-value services.” Such procedures include steroid injections for pain management, cervical fusion, arthroscopic knee surgery, diagnosis and treatment of impotence, and certain skin and tissue substitutes.

Washington state has more than 1.5 million Medicare enrollees, just over half of whom are enrolled in traditional Medicare. Until now, people with traditional Medicare have not been required to get prior authorization for most services. The privately-run alternative, Medicare Advantage, has lower premiums but limits provider networks and requires prior authorization.

Advocates say they fear WISeR’s use of AI to review claims of traditional Medicare users — a practice also used by Medicare Advantage — is blurring the lines between the two programs.

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In Washington’s case, the vendor chosen by the Centers for Medicare and Medicaid Services to run the WISeR program is Arizona-based Virtix Health.

Virtix and the other vendors are “compensated based on a share of averted expenditures,” according to the pilot program description. In other words, they are paid based on how many procedures they deny.

“WISeR is a dangerous program that is denying care to Medicare patients so companies can profit,” said U.S. Rep. Suzan DelBene, a Washington Democrat who is leading efforts in the House to repeal the program. “In just the first few months of the program, we’ve seen stories from across Washington state of seniors suffering while conditions worsen as they await approval for treatments their doctor prescribed.”

Representatives from 16 Washington hospitals reported that patients are now waiting two to four times longer to have procedures authorized, according to the Washington State Hospital Association. University of Washington Medicine said authorizations at its four hospitals that used to take one to three days now take 15 to 20 days.

“If someone is needing to wait and living every day in pain, there’s real consequences to their daily life,” said Jacqueline Barton True, an advocate with the state hospital association.

One of the problems Washington hospitals have encountered is that the Virtix interface is designed for individual and not organizational use, said Jennifer Brackeen, senior director of government affairs for the state hospital association.

“If I worked for a hospital and I was working on a claim, and then the next day I’m out sick, they weren’t able to follow up on that claim,” Brackeen said.

The WISeR model requires every claim denied using AI to be reviewed by a medical professional. But some Washington doctors are dubious that such a professional review is taking place, according to Jeb Shepard, policy director for the state medical association.

“To their mind, if a trained physician were reviewing it, they would never make some of the denials that are being made,” Shepard said.

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Virtix held a webinar on Wednesday with Washington state physicians. About 185 people signed up to take part in that conversation. Many submitted questions in advance.

But Shepard said on Thursday that Virtix did not address those questions or additional questions asked during the webinar in the chat, which was hidden from participants.

“They noted that the questions were coming through and that they would get to them at the end, and then we got to the end, and they said they would follow up with folks individually,” Shepard said. “So, I don’t have any fresh insight into how the program is going today.”

Meanwhile, Medicare Advantage has come under scrutiny for denying valid claims at a high rate. While most of those denials (more than 75%) are overturned on appeal, a large percentage of people (82%) don’t follow through after the initial denial, saving companies money but leaving patients without the care they need.

In addition to congressional investigations, companies that use AI to review Medicare Advantage claims are facing legal challenges.

A class action lawsuit filed in 2023 against insurance giant Humana said the company used proprietary algorithms to illegally deny coverage for Medicare Advantage patients. Another lawsuit filed the same year against UnitedHealth Group said some patients died before a final decision on their appeals to AI-generated denials were completed.

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“Prior authorization — especially when dictated by AI — creates major burdens and delays for patients and their doctors, and expanding it to traditional Medicare forces seniors to wait longer and navigate mountains of paperwork to get the care they are entitled to,” Democratic U.S. Sen. Patty Murray (WA) said in a statement. “AI should not get to decide what health care patients can and can’t receive.”

Virtix Health acknowledged procedural problems in the first months of its management of thousands of Medicare claims in Washington state, but said it was a natural part of the process.

“As with any pilot program, the implementation of prior authorization has presented challenges that have tested existing provider workflows to ensure patients receive the best care,” the company said in an email response to KUOW.

But physicians and hospitals say the problems they’ve experienced so far with Virtix go beyond growing pains. One physician in Central Washington reported that, even after he received approval from Virtix, the claim was denied by another company contracted to pay Medicare claims in Washington state.

“Physicians groups have hired full-time staff just to process prior authorizations on the commercial side,” Shepard said. “Now they’re being subjected to the same difficult processes on the traditional Medicare side. So, it’s pulling clinicians away from patient care.”

Virtix did not respond to KUOW’s follow-up questions about how it is dealing with communication and workflow challenges, or how much the company is making from “averted expenditures.”

In a report urging the government to delay implementation of WISeR last October, the American Heart Association said “participating vendors will be compensated by receiving 10-20% of the savings associated with care denials.”

After Democratic lawmakers were unable to stop WISeR’s implementation, they appealed to the federal Government Accountability Office, claiming the pilot program required congressional review. On May 12, the GAO agreed.

In the wake of that ruling, lawmakers in the House and Senate introduced Congressional Review Acts to repeal WISeR.

“This pilot program should never have been implemented without congressional oversight, and I call on my colleagues to stand up for Medicare patients and put a stop to WISeR,” Democratic U.S. Sen. Maria Cantwell (WA) said in a statement.

But the measures are unlikely to pass either chamber without Republican support, which has been lacking even though WISeR is being piloted in Republican strongholds such as Oklahoma, Ohio, and Texas. Arizona and New Jersey are also piloting the program.

Language for the program suggests the Centers for Medicare and Medicaid Services could expand WISeR in the coming years to include additional states and more procedures.

Rep. DelBene called WISeR “a trojan horse for privatizing Medicare” in an op-ed published in April.

“By injecting private companies into traditional Medicare with the goal of limiting care, the Trump administration is testing a new avenue to privatize the program,” DelBene said.

Shepard, with the Washington State Medical Association, said given the challenges physicians and hospitals are facing with WISeR and Virtix so far, the idea that the Centers for Medicare and Medicaid Services could expand the program to other services is a major concern.

“This is a program that’s applied to a pretty narrow set of services, to a small number of physicians treating patients, and they experienced significant challenges with the rollout of this program,” he said. “If [the Centers for Medicare and Medicaid Services] were to decide to expand the program more broadly to a large list of services, this could be massively disruptive to patient care.”

Stephen Howie is a reporter with KUOW. This story comes to you from the Northwest News Network, a collaboration between public media organizations in Oregon and Washington.

It is part of OPB’s broader effort to ensure that everyone in our region has access to quality journalism that informs, entertains and enriches their lives. To learn more, visit our journalism partnerships page.

News Source : https://www.opb.org/article/2026/05/30/washington-seniors-ai-medicare-review-program/