AI & Medicare: New Ohio Pilot Program Adds Prior Authorization for Some Procedures

Ohio is among the first states to participate in a new Medicare pilot program utilizing artificial intelligence (AI) to review certain medical procedures before they are approved for coverage. The program, formally known as the Wasteful and Inappropriate Service Reduction (WISeR) Model, launched in January 2026, and aims to curb unnecessary healthcare spending. While proponents suggest it’s a step towards efficiency, concerns are being raised about potential delays in care and the role of AI in medical decision-making.

What’s Changing for Medicare Patients?

For a select group of Medicare patients in Ohio, prior authorization will now be required for approximately a dozen outpatient procedures. This marks a significant shift for traditional Medicare, which historically has relied very little on prior authorization processes. These requests won’t be immediately processed by a physician; instead, they will initially be screened by AI systems developed by private companies contracted by the federal government. The AI is designed to identify patterns suggesting overuse or deviations from established clinical guidelines, potentially leading to a denial of coverage.

Ohio Medicare officials emphasize that human doctors will retain the final authority to approve or deny procedures, but the AI will serve as the initial review layer. This means a computer algorithm will first assess the request before it reaches a physician’s desk.

Potential Impact on Patient Care

The majority of Ohio Medicare beneficiaries will not experience any changes unless their doctor orders one of the procedures subject to prior authorization. However, for those patients, the process could introduce delays in receiving necessary care. Even relatively short delays can have consequences for patients’ health and well-being.

“Anytime you add a layer into the process of having to get approval to deliver care to someone, that can slow down the process,” explained Todd Baker, CEO of the Ohio State Medical Association. “It has the potential to add layers of administrative hassle, burden.” He further noted that delays could result in prolonged pain or worsening conditions before treatment can begin. There are also concerns that some seniors may interpret a denial as final and forgo appealing the decision.

Baker also questioned whether the potential cost savings would justify the added administrative burden. He expressed skepticism that there is sufficient fraud or inappropriate utilization to warrant the implementation of this new system, suggesting that savings may primarily come from patients and doctors abandoning the process altogether due to its complexity.

Arguments in Favor of AI-Assisted Prior Authorization

Supporters of the WISeR Model argue that AI can help identify and reduce unnecessary medical care, ultimately lowering Medicare costs. The technology could flag treatments that offer limited benefit to patients while contributing to rising healthcare expenses.

Jay Rayl, who runs Medicare Made Simple, a Medicare insurance agency in Cleveland, believes the impact on most patients will be minimal. “I think that when you really start looking at the kind of things that Medicare is starting to look at doing some authorizations with, it’s something that people do need to adjust to a little bit. It doesn’t typically become a huge problem,” he said. He added that prior authorization typically leads to delays rather than outright denials and represents a preferable approach to cost control compared to reducing benefits.

Rayl also pointed to the existing use of prior authorization in Medicare Advantage plans, suggesting that AI could streamline the process, provided human oversight remains in place for final decisions.

Concerns Regarding Artificial Intelligence and Prior Authorization

Patient advocates have voiced concerns about the potential for errors in an automated, AI-driven process. The shift from a doctor evaluating a patient’s individual circumstances to an algorithm comparing cases to a vast database raises the possibility that individuals with complex health issues could be flagged simply for falling outside the norm.

A broader concern centers on the increasing prevalence of prior authorizations in healthcare. Recent polling data from the nonpartisan KFF health policy organization reveals that prior authorization reviews are cited as the top health care problem by a significant portion of the population, with roughly one-third describing it as a major burden.

The success of this pilot program could significantly influence the future role of technology in Medicare patients’ care, whether welcomed by patients and physicians or not. If the program proves effective in reducing costs, it could pave the way for wider adoption of AI-assisted prior authorization across Medicare and potentially other healthcare systems.