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#14 - Medicare’s WISER Pilot: AI, Prior Auth, and the Cost of Care
What happens when an algorithm—not a doctor or a claims reviewer—denies your surgery? A single decision like that can trigger a much bigger conversation about how AI is reshaping access to care.
In this episode, we dive into Medicare’s WISER pilot and the complex world of prior authorization. What’s the goal? Reduce waste and streamline approvals. But where does it go wrong—and how can we fix it? With insights from AI researcher Vasan Sarati and emergency physician Laura Hagopian, we unpack how claims data trains decision-making models, why black-box algorithms erode clinician trust, and what real safeguards look like in practice.
We spotlight three high-volume services—skin and tissue substitutes, electrical nerve stimulators, and knee arthroscopy for osteoarthritis—and explore why these procedures made the list. Knee arthroscopy, in particular, becomes our case study: widely performed, weak evidence in most OA cases, but not without its exceptions. That tension reveals deeper risks: overreliance on flawed data, quick “human reviews,” and denials that feel rubber-stamped.
Then we imagine a better way. What if AI could argue with itself before deciding? Enter multi-agent models—a system where different specialized AIs represent the patient, the provider, and the payer. They debate function, evidence, policy, and risk—and their decisions come with plain-language justifications, escalation triggers, and audit trails. The goal: approvals that are not just faster, but fairer.
If you care about timely access, fewer roadblocks, and smarter AI guardrails in healthcare, this episode is for you. Subscribe, share it with a colleague, and tell us what you’d change about AI-driven prior auth. We’ll highlight listener ideas in an upcoming show.
Reference:
Private health insurers use AI to approve or deny care. Soon Medicare will, too.
Lauren Sausser and Darius Tahir
NBC News (2025)
WISeR (Wasteful and Inappropriate Service Reduction) Model
Cemter for Medicare and Medicaid Services
Credits:
Theme music: Nowhere Land, Kevin MacLeod (incompetech.com)
Licensed under Creative Commons: By Attribution 4.0
https://creativecommons.org/licenses/by/4.0/
View all episodes
By Vasanth Sarathy & Laura HagopianWhat happens when an algorithm—not a doctor or a claims reviewer—denies your surgery? A single decision like that can trigger a much bigger conversation about how AI is reshaping access to care.
In this episode, we dive into Medicare’s WISER pilot and the complex world of prior authorization. What’s the goal? Reduce waste and streamline approvals. But where does it go wrong—and how can we fix it? With insights from AI researcher Vasan Sarati and emergency physician Laura Hagopian, we unpack how claims data trains decision-making models, why black-box algorithms erode clinician trust, and what real safeguards look like in practice.
We spotlight three high-volume services—skin and tissue substitutes, electrical nerve stimulators, and knee arthroscopy for osteoarthritis—and explore why these procedures made the list. Knee arthroscopy, in particular, becomes our case study: widely performed, weak evidence in most OA cases, but not without its exceptions. That tension reveals deeper risks: overreliance on flawed data, quick “human reviews,” and denials that feel rubber-stamped.
Then we imagine a better way. What if AI could argue with itself before deciding? Enter multi-agent models—a system where different specialized AIs represent the patient, the provider, and the payer. They debate function, evidence, policy, and risk—and their decisions come with plain-language justifications, escalation triggers, and audit trails. The goal: approvals that are not just faster, but fairer.
If you care about timely access, fewer roadblocks, and smarter AI guardrails in healthcare, this episode is for you. Subscribe, share it with a colleague, and tell us what you’d change about AI-driven prior auth. We’ll highlight listener ideas in an upcoming show.
Reference:
Private health insurers use AI to approve or deny care. Soon Medicare will, too.
Lauren Sausser and Darius Tahir
NBC News (2025)
WISeR (Wasteful and Inappropriate Service Reduction) Model
Cemter for Medicare and Medicaid Services
Credits:
Theme music: Nowhere Land, Kevin MacLeod (incompetech.com)
Licensed under Creative Commons: By Attribution 4.0
https://creativecommons.org/licenses/by/4.0/