Bill Curry, 65, raises cattle on the identical land in rural Oklahoma as soon as owned by his father and generations earlier than him. Each quarter, for a number of years, he has made the 2½-hour drive to Oklahoma City for an epidural in his backbone to deal with his again ache.
But this 12 months, due to a brand new Medicare program, Curry has traveled a bit of extra usually.
In February, throughout one journey, he was advised unexpectedly that he wanted preapproval for the process. Then he went once more a month or so later to get the injection, for a complete of 10 hours on the street. His clinic wished him to return in a 3rd time, which they’d by no means requested of him earlier than. That appointment was “just to fill out a piece of paper to tell them how you feel again,” Curry mentioned, so he hasn’t gone.
In January, Oklahoma turned one in all six states to start a pilot program testing the use of preapprovals in conventional Medicare, the federal medical insurance program for folks 65 and older or with disabilities. Medicare had beforehand eschewed the observe — also referred to as prior authorization — which requires sufferers or somebody on their medical workforce to hunt insurance coverage approval earlier than continuing with sure procedures, exams, and prescriptions.
Epidurals like Curry’s are amongst 13 medical providers topic to the brand new program as a result of the Trump administration says they’re liable to fraud or misuse. Powered by synthetic intelligence, this system — referred to as the Wasteful and Inappropriate Service Reduction Model, or WISeR — is meant to save lots of the federal authorities cash and defend sufferers from doubtlessly unsafe or unneeded care.
Yet early opinions from Oklahoma and the opposite pilot states — Arizona, New Jersey, Ohio, Texas, and Washington — recommend WISeR’s rollout has not been clean. Patients, medical doctors, and different healthcare professionals who spoke with KFF Health News say the trouble has created confusion, errors, lengthy wait instances, and stress. Some described the rollout as “horrendous” and say folks enrolled in Medicare within the pilot states at the moment are getting ensnared in the identical pink tape as these with non-public insurance coverage.
One key concern is that all of it occurred too rapidly. WISeR was announced in June 2025 and launched in mid-January.
That was “quicker than normal” for the federal authorities, mentioned Todd Baker, who not too long ago stepped down as CEO of the Ohio State Medical Association. Doctors “just sort of had to figure it out,” added Jeb Shepard, director of coverage on the Washington State Medical Association.
Government contractors have additionally acknowledged the fast tempo. “We’ve had an aggressive rollout from the time of being notified to going live,” mentioned Jeremy Friese, CEO of Humata Health, the seller for Oklahoma. Tech executives servicing different states have mentioned they had been nonetheless including options to their merchandise within the spring.
Abe Sutton, director of the Center for Medicare and Medicaid Innovation, which is administering this system, didn’t touch upon the rollout schedule. But he mentioned in a press release that the aim of those reforms is to make sure that prior authorization is environment friendly, quick, and streamlined.
“The model aims to reduce inappropriate care without delaying appropriate care,” he mentioned.
Mehmet Oz, the chief of the Centers for Medicare & Medicaid Services, told NewsNation in December that they had been “rolling out some prior authorization on abused practices.”
“The purpose of these is not to deny care,” Oz continued. “It’s to make sure you get the care you need and deserve, not the care some unscrupulous doctor wants to use on you.”
Email Sign-Up
Medicare has struggled lately with suspected fraud related to explicit providers. The Department of Health and Human Services’ inspector normal warned in September that the program’s spending on pores and skin substitutes, for instance, had surged almost 700% over two years, elevating “major concerns about fraud, waste, and abuse.” Skin substitutes are among the many 13 therapies at present topic to overview beneath WISeR.
The program additionally imposes prior authorization necessities for kyphoplasty, a surgical procedure for spinal fractures, which a report by the Medicare Payment Advisory Commission flagged as overused.
Sutton acknowledged, nonetheless, that “the percentage of providers committing waste, fraud, and abuse is small.”
Consumers and clinicians largely detest prior authorization. Even as federal well being officers check the method for Medicare, the Trump administration is trying to scale it back for these with non-public insurance coverage. According to a KFF poll carried out in January, 69% of insured adults take into account prior authorization a burden for care.
Through WISeR, medical doctors and their workers log in to on-line portals to submit medical information that justify the procedures. Using synthetic intelligence, the methods rapidly approve functions that meet this system’s standards, Friese, Humata’s chief government, advised KFF Health News. He mentioned there’s an “immediate yes” in 88% of instances for which scientific information helps an approval.
CMS has touted the method as one during which selections are returned inside 72 hours. After that, clinicians obtain a “universal tracking number,” which permits them to schedule the process and receives a commission. In observe, nonetheless, members say the method is something however straightforward.
The University of Washington’s medical system alone had almost 100 sufferers ready earlier this 12 months for epidural injections resulting from WISeR-related delays, according to an April report from the workplace of U.S. Sen. Maria Cantwell (D-Wash.) that drew on hospital affiliation information. “Now, patients are subject to delays or denials which did not exist prior to the WISeR Model,” the report mentioned.
Curry, the Oklahoma cattle farmer, mentioned he would possibly go to Kansas for future therapies to keep away from the approval course of. Dorota Gribbin, a New Jersey-based bodily medication and rehabilitation doctor, mentioned that by the point authorization got here for one in all her sufferers who wanted a again ache process, the affected person had gone to the hospital for dearer care.
Jennifer Valle, a precertification and insurance coverage supervisor at Clinical Radiology of Oklahoma, mentioned in relation to kyphoplasties, there was a whole lot of “nitpicking” from reviewers. Other instances, data her observe offers to CMS will get missed, she mentioned, and reviewers ask for imaging that’s already within the file.
Claims with no issues are purported to be paid inside 15 days, mentioned James Webb, a musculoskeletal radiologist in Tulsa, Oklahoma, who has additionally been pissed off by the prior approval and reimbursement course of for kyphoplasties. “Six- to eight-week delays is what we’ve been seeing,” he mentioned.
“It’s been horrendous,” mentioned Jerry Sobel, a Phoenix-area ache administration physician. “Right from the beginning, there seemed to be no organization.” Sobel mentioned that as of May, he hadn’t gotten paid by Medicare for 9 epidurals.
“We continuously monitor operations and work closely with stakeholders to address questions and improve the provider experience,” mentioned Sundar Subramanian, the CEO of Zyter, which has the contract for Arizona.
During an April webinar, one other Zyter government acknowledged a big backlog in funds stretching to January. Those backlogs “are currently being resolved,” Medicare’s Sutton mentioned, with out offering additional element.
When requested about different points — together with what medical doctors suspect are AI-driven errors — Medicare’s Sutton mentioned the company appreciates “feedback on provider experience.” It can be used “to help providers better understand WISeR processes,” he mentioned.
Although CMS distributors say people make the ultimate selections on approvals, medical doctors and their staffs consider synthetic intelligence is taking part in a big position within the course of and that denials are generally the results of AI hallucinations that garble or make up data.
One Arizona physician, who wasn’t licensed by his observe to talk, recalled a denial saying his affected person wasn’t eligible for procedures within the thoracic area, or mid-back. The affected person wanted an injection to the neck. Webb, the Oklahoma radiologist, documented 4 instances {that a} affected person lacked numbness, and but his WISeR utility was nonetheless denied, citing numbness, which, within the reviewer’s interpretation, would rule out the spinal surgical procedure process.
Friese, Humata’s CEO, mentioned he hasn’t heard about any AI hallucinations.
The course of can be elevating authorities prices. With extra rejections, extra appeals are being filed with Medicare’s administrative contractors. The authorities pays the contractors to deal with the appeals, and Medicare’s Sutton acknowledged that the company has “accounted for potential changes in the volume of Medicare appeals because of the WISeR program and its associated costs.”
Eighty-four % of business insurers already use AI instruments, in line with a survey launched in 2025 by the National Association of Insurance Commissioners, although they’ve constantly mentioned AI isn’t used to disclaim prior authorization requests.
Its use in Medicare dangers introducing friction and frustration into this system — and piling prices onto its beneficiaries. Prior authorization saves cash for insurers partly by making sufferers pay a value in wait instances and inconvenience, mentioned Miranda Yaver, a University of Pittsburgh well being coverage researcher learning the method.
“People will end up getting ensnared in a lot of red tape, having to be on hold, and getting rerouted,” she mentioned. She usually wonders whether or not prior authorization merely shifts prices to sufferers and medical doctors, moderately than saving them.
Some medical doctors concerned in Medicare’s prior authorization experiment consider it can inevitably increase past a number of providers officers in Washington take into account fraud-prone.
“Everybody knows that if this pilot project works, it will be prior auth for basically all procedures,” mentioned Mary Clarke, a household observe doctor in Stillwater, Oklahoma. “If they can show that they can save money, then that’s going to be extrapolated and rolled out to other procedures and multiple other things in other states.”
When requested whether or not CMS is contemplating growth of its prior authorization pilot, Sutton mentioned in his assertion that there are “currently no changes” thought-about for the listing of providers topic to the WISeR program, “but CMS continues to assess whether any changes are warranted.”
Do you have an experience with prior authorization you’d like to share? Click here to inform KFF Health News your story.
KFF Health News Southern correspondent Lauren Sausser contributed to this report.
