Medicare official says parts of AI prior-authorization pilot are not working
Physician in the Loop, Oct 19, 2026
Listen to this post
read by AI voices ยท all episodesTHE SHORT READ
A senior Medicare official said Oct. 15 that "there are a lot of things about WISeR that are not working," referring to the agency's pilot of artificial intelligence-supported prior authorization in six states, Nextgov/FCW reported.
Kimberly Brandt, a deputy administrator of the Centers for Medicare & Medicaid Services, made the remark at a conference in Santa Fe, New Mexico, where her slides said the technology requires continuous oversight and that human clinical review is essential. Elsewhere, the Food and Drug Administration cleared an automated insulin pump for adults with insulin-treated type 2 diabetes, and three health systems said they have ended or are ending hospital-at-home programs.
THE DETAILS
- WatchRegulation Oct 15, 2026
CMS has published no changes to WISeR, which is scheduled to run through Dec. 31, 2031, according to the Congressional Research Service.
Kimberly Brandt made the remark Oct. 15 at the ADAPT conference in Santa Fe, New Mexico, and said Innovation Center staff "are committed to trying to get that right and get it better," Nextgov/FCW reported; her slides said the technology "requires continuous oversight" and that human clinical review is essential. WISeR began Jan. 1, 2026 in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington, and contractors use AI to review prior authorization requests for services including nerve stimulation, pain-related steroid injections, cervical fusion, knee arthroscopy for osteoarthritis and skin substitutes, with a clinician reviewing every denial, according to the Congressional Research Service. Providers and beneficiaries cannot opt out. A House committee advanced a provision to end the model in June, and the Senate has rejected efforts to stop it, Nextgov/FCW reported. Brandt also said CMS is piloting AI to flag suspicious Medicaid claims before payment. - FYIDeployment Oct 16, 2026Cone Health in Greensboro, North Carolina, said Oct. 14 that it will wind down its program in the fourth quarter, citing "evolving reimbursement models, operational complexity and long-term sustainability," Becker's Hospital Review reported. The program opened in April 2025, took no more than six patients at a time and reported no deaths or health care-acquired infections in its first year, the system said. Health First in Rockledge, Florida, is ending its program as part of cutting 214 positions, and Covenant Health in Knoxville, Tennessee, ended its program in April, according to Becker's. Congress has extended Medicare's Acute Hospital Care at Home waiver, which lets hospitals bill for inpatient-level care delivered at home, through Sept. 30, 2030, Becker's reported.Source: Becker's Hospital Review
- FYIRegulation Oct 16, 2026The clearance, announced Oct. 16, extends a system already indicated for type 1 diabetes in people 6 and older; its algorithm, based on the open-source Tidepool Loop, adjusts basal insulin continuously, the company said. In a 13-week pivotal study of 307 adults at 30 U.S. sites published in Diabetes Care, A1C fell an average of 0.7 point from a baseline of 8.1% and time in range rose from 57% to 73%, with no severe hypoglycemia, according to Sequel. Only 11% of participants had carbohydrate-counting experience, the company said. The pump is available by prescription through pharmacies and works with Abbott's FreeStyle Libre 3 Plus and Senseonics' Eversense 365 sensors, MassDevice reported.
- FYIEvidence Oct 16, 2026Women in the observational study started GLP-1 receptor agonist therapy, 99.8% of them tirzepatide, through a program with required blood tests, weekly video-supported follow-up and clinician-guided dose titration, and lost a mean 16.1 kg; 83.1% lost at least 10% of body weight, the authors reported. No serious treatment-related adverse events occurred, they said. The lead author is at University College London, and co-authors are affiliated with the online providers SheMed and eMed Healthcare UK, according to the PubMed record. The authors wrote that interpretation is limited by the observational design, the absence of a comparison group, a self-pay population and six months of follow-up.
- FYIMoney Oct 15, 2026The seed round, announced Oct. 15, was co-led by Fika Ventures and Evidenced Capital; Dr. Amol Navathe is a co-founder, Fierce Healthcare reported. The platform compares each referral, outpatient procedure and care transition with evidence-based standards in real time, and organizations using it removed prior authorization in some areas while keeping nonconcordant decisions below 5%, according to the company, which named no customers. Otter estimates that about 60% of low-value spending occurs outside traditional authorization controls.Source: Fierce Healthcare