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centers for medicare and medicaid services
Just Say No to AI-Assisted Medicare Preauthorization
A new AI-driven Medicare prior-authorization pilot could dramatically weaken Medicare, just another frightening step toward privatization and profiteering.
Sep 03, 2025
The odds are that if you have private health insurance or someone in your family has private health insurance, you have heard the dreaded phrase “we need preauthorization” from your insurance company. What this means is that your insurance company needs to approve in advance that your treatment or prescription is covered. In theory, this should be no big deal. However, reality is something else. But as the New York Times points out:
Private insurers often require a cumbersome review process that frequently results in the denial or delay of essential treatments that are readily covered by traditional Medicare. This practice, known as prior authorization, has drawn public scrutiny, which intensified after the murder of a UnitedHealthcare executive last December.
So, reading this you might think that you are glad that you or someone in your family choose traditional Medicare (in other words not a Medicare Advantage plan), so you would be able to avoid the “prior authorization needed” drama. Well, unfortunately you would be wrong as the prior authorization is slowly coming to Medicare. In late June, the Centers for Medicare and Medicaid Services (CMS) issued a press release:
The Centers for Medicare & Medicaid Services (CMS) is announcing a new Innovation Center model aimed at helping ensure people with Original Medicare receive safe, effective, and necessary care. Through the Wasteful and Inappropriate Service Reduction (WISeR) Model, CMS will partner with companies specializing in enhanced technologies to test ways to provide an improved and expedited prior authorization process relative to Original Medicare’s existing processes, helping patients and providers avoid unnecessary or inappropriate care and safeguarding federal taxpayer dollars. This model builds on other changes being made to prior authorization as announced by the US Department of Health and Human Services and CMS on Monday.
In theory, this move by CMS does not sound bad. Who could be against reducing wasteful spending in Medicare and making sure that people receive appropriate treatment? A spokesman for CMS has been quoted that the government would not review emergency services or hospital stays.
The CMS prior Medicare authorization model is being rolled out in January 2026 as a six-year trial program in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington State. In theory, the preauthorization program will look at those medical treatments that are not of benefit to Medicare beneficiaries.
What CMS is not drawing attention to is that this preauthorization will be done by artificial intelligence (AI)—or as CMS puts it “enhanced technologies.” It is not until much later in the press release that CMS gets to the fact that AI will do the screening authorization:
The WISeR Model will test a new process on whether enhanced technologies, including artificial intelligence (AI), can expedite the prior authorization processes for select items and services that have been identified as particularly vulnerable to fraud, waste, and abuse, or inappropriate use.
CMS, at the moment, says that the AI preauthorization screening will be used on only an extremely limited number of procedures. But what guarantees do Medicare beneficiaries have? The bottom line is that you have to ask yourself: Would you be comfortable having your access to your earned Medicare benefits be determined by AI? My answer is a firm, “No, thank you.”
We also need to ask what are the financial incentives that Medicare is injecting into the system though preauthorization? It is hard not to conclude that this is a step toward privatization of traditional Medicare.
Healthcare professionals are concerned by CMS’ preauthorization program. In mid-July, the American Medical Association (AMA) wrote to CMS:
While the stated goal of the model is to curb wasteful spending and protect the Medicare Trust Fund, the mechanisms employed raise several significant issues that must be addressed prior to implementation. The AMA strongly urges CMS to pause the January 1, 2026 implementation of the WISeR Model to allow additional stakeholder input, full analysis of the model’s operational impacts, and development of clear guidance for physicians. Physicians should not be forced to adapt to such substantial administrative requirements without sufficient time to understand the implications and prepare. Absent this opportunity for meaningful physician and stakeholder engagement, the model risks creating confusion, administrative burden, and unintended consequences that could ultimately undermine CMS’ own goals to reduce waste, fraud, and abuse.
On Capitol Hill, a number of House Democrats led by Rep. Alexandria Ocasio-Cortez of New York have pushed back on the AI preauthorization pilot project. In late July, they wrote to CMS:
We understand that CMMI has intentionally selected healthcare services that are reported to have limited clinical value and may be vulnerable to abuse in the Medicare program, and we support efforts to ensure Medicare remains a good steward of taxpayer dollars. However, the expansion of AI-fuelled prior authorization will not improve program integrity in Traditional Medicare. Giving private for-profit actors a veto over care provided to seniors and people with disabilities in Traditional Medicare, even as a pilot program, opens the door to further erosion of our Medicare system. We therefore strongly urge you to immediately halt the proposed WISeR model and instead consider steps to address the well-documented waste, fraud, and abuse in the Medicare Advantage program.
The House Democrats raise a very intriguing question about why CMS is not focused more on fighting waste, fraud, and abuse in Medicare Advantage plans? As the Center for Budget and Policy Priorities reported in January of this year, there is considerable evidence to show that Medicare Advantage plans are overpaid by the government. It would make sense for CMS in pursing fraud and waste to follow the money which means looking at Medicare Advantage plans.
Give the political dynamics in Washington, it seems likely that the CMS preauthorization demonstration project will go into effect in January 2026. Then in the summer of 2026, with the midterm elections looming, as members of Congress will begin hearing from constituents who have had their earned Medicare benefits denied by AI, Congress will revisit this issue. It is tragic that in the meantime people will be hurt.
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Report Highlights Threat Posed by 'Trump Health Cabal'
"Trump has nominated unqualified and dangerous people to serve in the most important health positions in the country," said Eagan Kemp, the author of the report for the consumer advocacy group Public Citizen.
Jul 30, 2025
The government watchdog group Public Citizen published a report on Tuesday warning that U.S. President Donald Trump's "dangerous health cabal threatens patients, providers, and the programs they rely on."
The report, written by healthcare policy advocate Eagan Kemp, takes aim at several of Trump's appointees to top healthcare posts. Among those highlighted are Secretary of Health and Human Services (HHS) Robert F. Kennedy Jr., Centers for Medicare and Medicaid Services (CMS) head Mehmet Oz, Deputy HHS Secretary Jim O'Neill, and surgeon general nominee Casey Means.
"The first few months of the Trump administration have brought chaos and disaster to an already fragmented and dysfunctional health care system," the report says. "From efforts to make massive cuts to the ACA and Medicare and layoffs of huge numbers of HHS staff across the agency, it is tough to keep up with all the damage being done."
Kennedy, the report says, has aggressively promoted "conspiracy theories and dangerous anti-science views" during his time as HHS secretary.
The report notes Kennedy's fear-mongering about the safety of the highly effective measles vaccine as the U.S. experienced the largest outbreak in recent years, and his purge of credentialed independent experts from the panel that makes national vaccine recommendations in favor of a clique of anti-vaccine activists.
The report also points to Kennedy's decision to de-emphasize research into infectious disease and prescription drugs and his mass firings at other agencies within HHS, including the Food and Drug Administration (FDA) and the National Institutes of Health (NIH).
"With Kennedy taking command of the HHS, Americans are presented lies and disinformation at an unprecedented scale that are capable of unwinding a century of progress on fighting disease and promoting public health," it says.
The report also highlights Oz's efforts to further privatize Medicare by championing Medicare Advantage, which it says "would leave more Americans at the whim of greedy health insurance corporations." It cites one study, which found that since 2007, overpayments to private Medicare providers added up to more than $600 billion, and could amount to another trillion over the next decade.
Additionally, the report cites findings from the Government Accountability Office (GAO) that patients with significant healthcare needs were more likely to drop Medicare Advantage in favor of returning to traditional Medicare, which it says "indicates that these patients were unable to receive necessary care" under the privatized program.
It describes Oz's "massive conflicts of interest," including his six-figure investments in Medicare Advantage providers like UnitedHealth and CVS Health.
"Medicare Advantage plans regularly deny needed care, making it difficult for low-resource hospitals to remain open to serve the public," the report says."If Oz gets his wish of further expanding Medicare Advantage, it will threaten the solvency of many hospitals, particularly rural hospitals currently at risk of closure, as they would struggle to keep their doors open because they wouldn't have the consistent funding they need to continue serving their communities."
O'Neill, who was appointed last month as Kennedy's deputy at HHS, is described as "a long-time venture capital investor with concerning views that reflect his significant financial ties to for-profit biomedical companies," adding that "his interests run counter to [HHS's] public health mandate."
The report notes O'Neill—a staunch libertarian—is opposed to FDA regulations to ensure the safety and efficacy of drugs, which he said "kill a lot of people and provide a lot of harm to the economy."
He has called to eliminate the agency's mandate to ensure that drugs are effective before they are approved for sale. In a 2014 speech to a biotech group, O'Neill said the FDA should "let people start using them, at their own risk."
As an official in the George W. Bush administration's HHS, he also opposed FDA regulations on diagnostic tests that rely on computer algorithms—an even more pressing issue today given the increasing ubiquity of artificial intelligence, including in healthcare.
"While he has a limited public record of comments on health issues broadly," the report says, "his dangerous and misinformed views about the workings of the FDA provide deep cause for concern that he will prioritize ideological and corporate profit considerations over the public health mandate of the department."
Means, Trump's pick for surgeon general—who would be the top authority on public health recommendations—is described as having "little to no managerial experience in the context of government agencies or scientific research."
She does not have an active medical license, and dropped out of her surgical residency. According to colleagues, she did so after coming to believe "that modern medicine is a conspiracy to keep people sick."
A "wellness influencer" in the mold of Kennedy, she has a history of anti-vaccine views and has advocated for getting rid of the Hepatitis B vaccination for babies, which is credited with reducing HBV infection by 68% over a decade after its introduction in 1991. Means has also said that birth control pills are overprescribed, and that they signal a "disrespect of life."
She also stands to potentially profit from her decisions as surgeon general, the report says, since she remains the chief medical officer of a glucose monitoring technology company and has not stepped down from her post despite the possible conflicts of interest.
"The range of unscientific ideas, wellness products, and conspiratorial claims that Means is associated with," the report says, "makes her a potentially dangerous person to serve in a role that requires being a credible health communicator for the country and upholding sound science."
The state of healthcare in the United States, the report says, is about to become more precarious following the passage of the "One Big Beautiful Bill Act," which is projected to result in 10 million people losing their health insurance. Medicare privatization has also accelerated, with hiked rates for Medicare Advantage plans.
"The fact that Trump, Kennedy, and their allies have taken so many dangerous and misguided actions on health in just the early months of the new administration," the report says, "highlights the need for vigilance and strong pushback from anyone who wants a better healthcare system."
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'Terrible Development': Trump Admin Restricts State Efforts to Help Kids Stay on Medicaid
"The Trump administration will stop at nothing to rip coverage away from American families, even kids they claim they want to protect," said Sen. Ron Wyden.
Jul 18, 2025
The Trump administration on Thursday said it will restrict waivers that have allowed states to keep kids enrolled in Medicaid or the Children's Health Insurance Program beyond the 12-month period of continuous coverage required under federal law.
The Centers for Medicare and Medicaid Services (CMS), led by Mehmet Oz, announced the move on Thursday, saying that it has informed states of a "clear shift away from policies that extend beyond statutory limits," specifically restricting Section 1115 waivers that have been sought and approved in dozens of states across the U.S.
"CMS will allow currently approved initiatives to run out their course but does not anticipate extending them nor approving new waivers," the agency said in a statement, which came less than two weeks after President Donald Trump signed into law the largest Medicaid cuts in U.S. history.
Sen. Ron Wyden (D-Ore.), the top Democrat on the Senate Finance Committee, called the CMS announcement a "terrible development" and "yet one more awful example of the Trump administration's obsession with making it as hard as possible for Americans to access the healthcare they are eligible for."
In 2022, Oregon became the first state in the nation to receive federal approval to provide children with continuous Medicaid coverage from birth up to age 6 through a Section 1115 waiver. The policy was described as a "ground-breaking initiative" that would "help infants and young children get off to a healthy start in life without parents having to worry about renewing their Medicaid coverage annually," regardless of temporary changes to family income or other factors.
The CMS announcement points to the Oregon policy without explicitly naming the state. Oregon's federal waiver is set to expire in 2027.
Wyden said Thursday that "the Trump administration will stop at nothing to rip coverage away from American families, even kids they claim they want to protect."
Joan Alker, executive director of Georgetown University's Center for Children and Families, wrote that "in the name of 'protecting vulnerable Americans,' the Trump administration will rip away Medicaid coverage from babies and toddlers."
👀In the name of “protecting vulnerable Americans” the Trump Administration will rip away Medicaid coverage from babies and toddlers👀
CMS announces Medicaid demos that 8 states are implementing to cover babies and young children continuously w/o gaps will no longer be allowed pic.twitter.com/aXF0mKXL9S
— Joan Alker (@JoanAlker1) July 17, 2025
CMS insisted that the newly announced changes are aimed at protecting Medicaid's finances by ensuring that those who are no longer eligible for the program are removed.
But Amaya Diana, a policy analyst at the health research organization KFF, wrote Thursday that "not everyone who loses coverage at renewal is no longer eligible."
"During the unwinding of the [pandemic-era] Medicaid continuous enrollment provision, seven in 10 Medicaid enrollees who lost coverage were disenrolled for procedural reasons," Diana noted. "While some were no longer eligible, others lost coverage due to barriers such as communication issues."
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