Source: Health Policy Institute of Ohio
Federal officials have named Ohio as one of six states to test the use of artificial intelligence (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, The Columbus Dispatch, September 18).
The six-year pilot program, which begins Thursday, January 1, and is called the Wasteful and Inappropriate Service Reduction Model (WISeR), aims to reduce overspending and fraud. The Centers for Medicare and Medicaid Services (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 CMS.
CMS estimated that 25% of all healthcare 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.