Senate Democrats failed Thursday to kill an artificial intelligence (AI)-driven prior authorization demonstration program for traditional Medicare, but they say this isn't the end of the road.
"Democrats tried to stop AI prior authorization in Medicare," Sen. Patty Murray (D-Wash.) wrote on X after the vote was taken. "Republicans blocked it -- apparently they agree with Trump that AI knows better when it comes to healthcare decisions for our seniors. This isn't the end. We'll keep fighting back."
In June 2025, the Centers for Medicare & Medicaid Services (CMS) announced a new demonstration project in traditional Medicare: the Wasteful and Inappropriate Service Reduction (WISeR) Model. Under the model, "CMS will partner with companies specializing in enhanced technologies to test ways to provide an improved and expedited prior authorization process" in traditional Medicare, the agency said in a press release, adding that the model will help "patients and providers avoid unnecessary or inappropriate care and [will safeguard] federal taxpayer dollars."
The WISeR model tests new technologies -- including AI -- to see whether they can expedite the prior authorization processes for certain items and services "that have been identified as particularly vulnerable to fraud, waste, and abuse, or inappropriate use," the press release noted. "These items and services include, but are not limited to, skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy for knee osteoarthritis."
Emergency services and inpatient-only services are exempt from the model, which will initially be tested in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington. Although prior authorization is used frequently in Medicare Advantage plans, which are run by private insurers, it has been used sparingly in traditional Medicare.
The model is "voluntary" for providers, but "providers and suppliers in the assigned regions will have the choice of submitting prior authorization requests for selected items and services or their claim will be subject to pre-payment medical review," the agency noted, so either way the claims for the affected services will be reviewed.
The program, which began in January, has come in for lots of criticism, with patients and clinicians saying it has created confusion and long wait times. Some described the rollout as "horrendous" and say people enrolled in traditional Medicare in the pilot states are now getting ensnared in the same red tape as those with private insurance.
The administration has defended the program as a way to root out Medicare fraud. "It's our duty as Americans to stop fraud and protect patients from potential harm," Abe Sutton, director of the Center for Medicare and Medicaid Innovation, told MedPage Today at a primary care meeting in Washington, D.C., on Tuesday.
One of the listed services subject to the program, skin and tissue substitutes, has been cited for rampant profiteering, with one Medicare beneficiary in Florida accumulating costs of $9.8 million in about a year. A data analysis released in 2025 projected that Medicare would spend as much as $15.4 billion by the end of that year on skin substitutes. Medicare has since issued a regulation limiting reimbursement for the materials to $127.28 per cm2. But makers of the skin substitutes counter that the new rate will cause providers to turn to inferior products potentially made by foreign sources.
Senate and House members representing the affected states have pushed back on the new model. In the Senate, a resolution introduced by Sen. Ron Wyden (D-Ore.), ranking member of the Senate Finance Committee, would have terminated the WISeR program. It failed Thursday by a vote of 46-50, prompting the X post from Murray.
"President Trump came into office saying he would not cut Medicare, but that was clearly a lie," Murray said prior to the vote. "Because right now, his administration is trying to privatize Medicare, in part by putting AI between Medicare beneficiaries and their healthcare."
Before the vote, Wyden noted that "seniors paid into Medicare out of every paycheck during their working years, and they did so with an expectation they would have an ironclad guarantee of affordable healthcare."
"Today, seniors in six states across America are discovering that care their doctor has recommended for them has been slowed or halted by a shadowy AI-driven third party," he said. "The consequences are not abstract. Seniors with severe back pain have to wait weeks for relief, upending their lives and leaving them suffering because of the bureaucracy of healthcare."
But Sen. Mike Crapo (R-Idaho) disagreed. "Far too often our nation's healthcare system incentivizes low-value, high-cost services," he said prior to the vote. "For years, bipartisan policymakers throughout Capitol Hill and across administrations have endeavored to disrupt this flawed paradigm, especially in the Medicare program. Unfortunately, despite progress to incorporate new, value-based payment arrangements, Medicare's underlying reimbursement structure continues to rely heavily on the volume of services provided rather than the quality of care. In addition to failing patients and providers, Medicare's perverse financial incentives contribute to massive waste and abuse."
"Every member of this body agrees that patients should have access to high-quality care, providers deserve predictable payment for services, and avoidable waste, fraud, and abuse in Medicare should be stopped," said Crapo. "Ending this pilot program prematurely will deprive CMS of a useful tool to accomplish each of those goals. And I urge my colleagues to consider the facts and oppose this resolution."
Over in the House, Rep. Suzan DelBene (D-Wash.) also introduced a bill to stop the program. Her measure has 43 cosponsors -- all Democrats -- but has not advanced further.
"The outcome of the Senate ... vote was incredibly disappointing," DelBene told MedPage Today in a text message on Friday. "Republicans refuse to stand up to the president even as his AI Medicare experiment delays care for seniors across the country, leaves them in pain for weeks, and worsens health outcomes. We will continue fighting to end this dangerous program so seniors can get the care they need when they need it."
https://www.medpagetoday.com/practicemanagement/reimbursement/122254
