US pilots AI for insurance approvals—but doctors fear faster denials

Prior authorization—the process by which patients must seek pre-approval from insurers before receiving certain medical treatments—has long been a source of friction in American healthcare. Physicians and patients report significant delays in care, and a Commonwealth Fund survey found roughly one in five working-age Americans with private insurance experienced a denial in 2025, with 41 percent saying it delayed their care and more than a quarter reporting their health worsened as a result. The Biden administration attempted reform in 2024, requiring insurers to make urgent decisions within 72 hours and non-urgent ones within seven calendar days, rules that went into effect January 1, 2025. Private insurers have pledged to standardize electronic requests by 2027 and reduce prior authorization volume for common procedures like colonoscopies and cataract surgeries by 2026.

The Trump administration's WISeR pilot represents a new approach: rather than lightening the prior authorization burden, it extends AI-driven authorization into original Medicare—where prior authorization has been rare—while simultaneously pressuring private insurers to ease their own processes. CMS Administrator Mehmet Oz has told insurance executives to streamline the process or face federal regulation. Yet the financial structure of WISeR creates a potential misalignment: vendors are compensated based on "averted expenditures," meaning they profit when claims are rejected. This echoes a longstanding concern in American healthcare about incentives to deny necessary care. Early reports from the pilot's first months indicate delays and some denials in all six participating states, suggesting the system may not be delivering the promised speed or appropriateness.