Trump’s AI Medicare Gatekeeper Pilot Sparks Concerns Over Care Quality
The Rise of AI in Healthcare and Its Implications
Artificial intelligence (AI) is increasingly becoming a part of everyday life, especially in the healthcare sector. However, its integration into medical systems is not without controversy. One notable example is the Trump administration’s plan to introduce a new program in 2026 that uses AI to approve or deny care for Medicare enrollees. This initiative, known as the Wasteful and Inappropriate Service Reduction (WISeR) program, aims to streamline the prior authorization process, which requires providers to get approval from Medicare plans for certain treatments or diagnostic tests.
The pilot program will roll out on January 1 and is set to run through 2031. During this time, Medicare patients, providers, and facilities in Arizona, Ohio, Oklahoma, New Jersey, Texas, and Washington will be impacted. While the program could lead to significant savings, it also raises concerns about potential denials of necessary care for older Americans.
Understanding Prior Authorization
Prior authorization is a common practice in healthcare, particularly for Medicare Advantage plans. It ensures that expensive care is not given unnecessarily. However, many providers and Medicare enrollees view it as a barrier to timely treatment. A recent Kaiser Family Foundation (KFF) survey found that 73% of people believe delays and denials of treatment by health insurers are a major problem. Additionally, a 2025 KFF report revealed that Medicare Advantage made nearly 50 million prior authorization decisions in 2023 alone, with 99% of enrollees in an Advantage plan subject to prior authorizations for at least some services.
In 2023, 6.4% of prior authorization requests were denied, a slight decrease from the 7.4% in 2022. However, the fear remains that the WISeR program could result in more denials. Critics worry that the use of AI in this process might prioritize cost-saving over patient care, leading to potential harm for those who need timely medical attention.
CMS’s Claims and Concerns
The Centers for Medicare & Medicaid Services (CMS) claims that WISeR, using AI technology, will help ensure that Medicare beneficiaries receive the most appropriate care while decreasing costs and easing administrative burdens. They emphasize that human clinical review will be part of the process, ensuring that decisions are not solely made by computers. Certain services, such as inpatient-only services, emergency care, or treatments that pose a significant risk if delayed, will not be subject to AI assessment.
Additionally, CMS has stated that vendors will be prohibited from compensation arrangements tied to denial rates. This is intended to prevent financial incentives that could lead to unnecessary denials of medically appropriate care. However, there are already concerns about increased denials. A 2025 American Medical Association (AMA) survey found that 61% of physicians believe their health plans’ use of AI is leading to more prior authorization denials.
Protecting Yourself as a Medicare Enrollee
If you’re worried about being denied care as a Medicare enrollee, there are several steps you can take to protect yourself:
- Stay up to date: Follow the topic for updates on the pilot program, especially in your state, so you know what challenges other beneficiaries might face.
- Choose your plan carefully: If you haven’t signed up for a Medicare Advantage plan, check its rating. Medicare uses a star rating system to rank Advantage plans based on different criteria.
- Read through your plan carefully: Review your Medicare Advantage plan’s evidence of coverage, which provides details on what the plan covers and what costs you can expect.
- Document everything: Get full documentation from your providers when dealing with a medical issue. If you’re denied treatment, demand an explanation to review with your providers.
- Appeal: Medicare Advantage plans have an appeals process you can follow if a prior authorization request is denied. Plans typically offer a 30-day window for pre-service appeals and 60 days for payment-related appeals.
- Speak to your plan admin directly: If your state is part of the WISeR program, talk to your Medicare plan administrator and providers about your concerns. Ask about the criteria used for decisions and confirm everything in writing.
- Choose providers carefully: Seek out providers who are patient and thorough, as they may be more willing to fight for you in the event of a denial.
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