There Is a New Doctor in Town, Doctor AI
As a boy in a small rural Georgia town, I remember hearing that “a new doctor” had arrived with a glass neck—Dr. Pepper—and rushing to the gas station to try it for the first time. Today, I want to introduce another new doctor in town: Dr. AI. Like so many inventions born from necessity and mankind’s desire to make life easier, from matches and wheels to cars—AI represents the latest step in our ongoing search for faster, more efficient ways to solve problems.
If John Henry was here today, he might not be very happy with the replacement of human resilience with “Artificial Intelligence” (AI). What would George Jetson think of our world today?
So, what does Dr. AI bring to the table? In an article written by Diego Perez Morals, Morals tells of a groundbreaking move by the Centers for Medicare and Medicaid (CMS). Starting in January 2026, a pilot program, called “Wasteful and Inappropriate Services Reduction (WISeR),” aimed at enhancing efficiency by minimizing unnecessary medical services. This program’s design is to protect taxpayer funds while ensuring that only essential treatments receive approval. New technology can be unpleasant to some but if the end result is a savings to the people, should we at least try?
This program was rolled out in six states and targeted 17 specific outpatient services. AI will make the preliminary assessment, but licensed clinicians will oversee the assessments and make the ultimate decisions. The hope is that AI could weed out unnecessary procedures and lower costs for the insurance companies. The problem is that this could alter service approvals for much needed care. Just this past week, NBC News, reported that Medicare Advantage plans are denying prior authorization requests at unusually high rates. While this news report was not speaking of AI generated prior authorization, it reveals some of the inherited concerns that people have. Berkeley Lovelace Jr. stated, “Patients enrolled in some of the nation’s largest Medicare Advantage plans were denied requests for rehabilitation and other critical services at unusually high rates, according to a report released Thursday by the Department of Health and Human Services’ inspector general.”
Lovelace said the range of denial is from 8% to 80%. Most patients are not taking advantage of the appeal process when there is a denial. When an appeal is filed, 95% of these appeals are approved. What happens to those who do not file an appeal? They go without treatment and many times their medical condition deteriorates. What is likely to happen when prior authorization requests are handled by AI, when there is no human interaction in the decision-making process?
In his report, Lovelace noted, “Medicare Advantage plans get a fixed amount of government funding per patient and can keep more money if they keep healthcare costs low, including through prior authorization.” Lovelace reported that Health Secretary Robert F. Kennedy Jr. has vowed to take steps to reform prior authorization by limiting the service that can be denied.
The WISeR study will end in 2030 and if this study satisfies CMS’s desire to eliminate wasteful spending through AI prior authorization, we might see this process in all states.
My encouragement to all Medicare clients experiencing a denial for service is to work with your doctors to file an appeal. A four-step process to filing an appeal should be taken:
1. Review the denial notice – an explanation of the denial and how to appeal.
2. Gather supporting documentation – A letter from the doctor, medical records, or other evidence showing the service is medically necessary.
3. Submit the appeal within the deadline – Medicare Advantage plans generally allow 60 days from the denial notice to request an appeal.
4. Request an expedited appeal if urgent – If waiting could seriously affect the member’s health, a faster review may be available.
Reducing wasteful spending is a good thing and Dr. AI can help. Fully use your rights of appeals for the necessary procedures.
Join the more than 1,400 clients who have trusted Hillary Broome for Medicare guidance. Take the next step toward understanding your options—schedule your appointment today.