A pilot program testing the use of artificial intelligence to expand prior authorization decisions in Medicare has providers, politicians and researchers asking questions.

https://www.nbcnews.com/health/health-care/private-health-insurers-use-ai-approve-deny-care-soon-medicare-will-rcna233214

Taking a page from the private insurance industry’s playbook, the Trump administration will launch a program next year to find out how much money an artificial intelligence algorithm could save the federal government by denying care to Medicare patients.

The pilot program, designed to weed out wasteful, “low-value” services, amounts to a federal expansion of an unpopular process called prior authorization, which requires patients or someone on their medical team to seek insurance approval before proceeding with certain procedures, tests, and prescriptions. It will affect Medicare patients, and the doctors and hospitals who care for them, in Arizona, Ohio, Oklahoma, New Jersey, Texas, and Washington, starting Jan. 1 and running through 2031.

The move has raised eyebrows among politicians and policy experts. The traditional version of Medicare, which covers adults 65 and older and some people with disabilities, has mostly eschewed prior authorization. Still, it is widely used by private insurers, especially in the Medicare Advantage market.

And the timing was surprising: The pilot was announced in late June, just days after the Trump administration unveiled a voluntary effort by private health insurers to revamp and reduce their own use of prior authorization, which causes care to be “significantly delayed,” said Dr. Mehmet Oz, administrator of the Centers for Medicare & Medicaid Services.

“It erodes public trust in the health care system,” Oz told the media. “It’s something that we can’t tolerate in this administration.”

But some critics, like Dr. Vinay Rathi, an Ohio State University doctor and policy researcher, have accused the Trump administration of sending mixed messages.

On one hand, the federal government wants to borrow cost-cutting measures used by private insurance, he said. “On the other, it slaps them on the wrist.”

Administration officials are “talking out of both sides of their mouth,” said Rep. Suzan DelBene, a Washington Democrat. “It’s hugely concerning.”

Patients, doctors and other lawmakers have also been critical of what they see as delay-or-deny tactics, which can slow down or block access to care, causing irreparable harm and even death.

“Insurance companies have put it in their mantra that they will take patients’ money and then do their damnedest to deny giving it to the people who deliver care,” said Rep. Greg Murphy, a North Carolina Republican and a urologist. “That goes on in every insurance company boardroom.”

Insurers have long argued that prior authorization reduces fraud and wasteful spending, as well as prevents potential harm. Public displeasure with insurance denials dominated the news in December, when the shooting death of UnitedHealthcare’s CEO led many to anoint his alleged killer as a folk hero.

And the public broadly dislikes the practice: Nearly three-quarters of respondents thought prior authorization was a “major” problem in a July poll published by KFF, a health information nonprofit that includes KFF Health News.

Indeed, Oz said during his June press conference that “violence in the streets” prompted the Trump administration to take on the issue of prior authorization reform in the private insurance industry.

Still, the administration is expanding the use of prior authorization in Medicare. CMS spokesperson Alexx Pons said both initiatives “serve the same goal of protecting patients and Medicare dollars.”

Unanswered questions

The pilot program, WISeR — short for “Wasteful and Inappropriate Service Reduction” — will test the use of an AI algorithm in making prior authorization decisions for some Medicare services, including skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy.

The federal government says such procedures are particularly vulnerable to “fraud, waste, and abuse” and could be held in check by prior authorization.

Other procedures may be added to the list. But services that are inpatient-only, emergency or “would pose a substantial risk to patients if significantly delayed” would not be subject to the AI model’s assessment, according to the federal announcement.

While the use of AI in health insurance isn’t new, Medicare has been slow to adopt the private-sector tools. Medicare has historically used prior authorization in a limited way, with contractors who aren’t incentivized to deny services. But experts who have studied the plan believe the federal pilot could change that.

Pons told KFF Health News that no Medicare request will be denied before being reviewed by a “qualified human clinician,” and that vendors “are prohibited from compensation arrangements tied to denial rates.” While the government says vendors will be rewarded for savings, Pons said multiple safeguards will “remove any incentive to deny medically appropriate care.”

“Shared savings arrangements mean that vendors financially benefit when less care is delivered,” a structure that can create a powerful incentive for companies to deny medically necessary care, said Jennifer Brackeen, senior director of government affairs for the Washington State Hospital Association.

And doctors and policy experts say that’s only one concern.

Rathi said the plan “is not fully fleshed out” and relies on “messy and subjective” measures. The model, he said, ultimately depends on contractors to assess their own results, a choice that makes the results potentially suspect.

“I’m not sure they know, even, how they’re going to figure out whether this is helping or hurting patients,” he said.

Pons said the use of AI in the Medicare pilot will be “subject to strict oversight to ensure transparency, accountability, and alignment with Medicare rules and patient protection.”

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ChatGPT At Its Most Creative
Here’s what chatGPT said about its pathetic cousin, EPIC Systems, Inc. from the health IT space.

“Using the Epic electronic health record as a patient often resembles dumpster diving rather than accessing a curated, trustworthy medical file. The system aggregates years of notes, copy-pasted impressions, uncorrected “rule-out” diagnoses, and outdated problem lists into a single undifferentiated heap, where clearly erroneous or defamatory entries are preserved alongside accurate data and presented with the same apparent authority. Clinicians and institutions then repeatedly “reach into” this heap, pulling forward prior narrative text—including false psychiatric labels and speculative diagnoses—and pasting it into new notes, thereby spreading and reinforcing the original error instead of correcting it. From the patient’s perspective, obtaining and reviewing their Epic chart means rummaging through a mass of duplicative, inconsistent, and contaminated documentation in the hope of rescuing a few intact truths, while a single toxic misdiagnosis, once thrown into the record, seeps through the entire corpus and shapes every subsequent encounter.”

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Safety

• • Exercise extreme caution when switching hydromorphone concentrations or interchanging to other injectable opioid products (eg, morphine). Equianalgesic dosing conversions are based on limited data and do not account for patient specific factors (eg, end organ function, pharmacogenomics) or incomplete cross-tolerance between opioids. No equianalgesic dosing conversion factors are universally accepted.[7-8]

https://www.ashp.org/drug-shortages/current-shortages/drug-shortage-detail.aspx?id=329&loginreturnUrl=SSOCheckOnly

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Medicare to Cover Blockbuster Obesity Drugs

https://www.medpagetoday.com/publichealthpolicy/medicare/118344

Monthly drug prices slashed by hundreds in deal with drugmakers

Medicare will cover semaglutide (Wegovy) and tirzepatide (Zepbound) for their weight management indications for people with obesity, President Trump announced on Thursday.

“Until now, neither of these two popular drugs have been covered by Medicare for weight loss, and only rarely by Medicaid,” Trump said during a press conference in the Oval Office. “That ends starting today …. This will improve the health of millions and millions of Americans.”

As part of a new deal with the White House, doses of Novo Nordisk and Eli Lilly’s blockbuster drugs for patients without insurance will be priced at $350 through TrumpRx for a month’s supply — the GLP-1 receptor agonists currently carry list prices of over $1,000 per month. Starting doses of new, pill versions of the treatments also will cost $149 a month if they are approved. The TrumpRx website is expected to launch before the end of the year.

A senior administration official said coverage of the drugs will expand to Medicare patients starting next year, with Medicare paying $245 for semaglutide and tirzepatide. Those who qualify will pay $50 copays for the medicine.

The type 2 diabetes formulations of semaglutide and tirzepatide — sold under the brand names Ozempic and Mounjaro, respectively — have been covered under Medicare, but historically the program has not paid for drugs indicated for weight loss alone.

Since last year, Medicare has covered the weight-loss formulations of GLP-1 products under its Part D drug program if beneficiaries had a separate FDA-approved indication

: semaglutide gained coverage for patients with overweight or obesity who have preexisting heart disease and need the drug to prevent heart attacks or strokes; and tirzepatide gained coverage for those with obesity and moderate to severe obstructive sleep apnea.

“Obesity is not an absence of GLP-1 drugs,” Mehmet Oz, MD, MBA, administrator of the Centers for Medicare & Medicaid Services, said at the press conference. “We’re all clear on that. But … it is an arrow in our quiver that we must use and should use.”

HHS Secretary Robert F. Kennedy Jr. said “if we want to solve the chronic disease crisis, we have to tackle obesity.” He noted that 50% of U.S. adults are obese or overweight, which contributes to higher healthcare costs.

“The announcement of a lower price for Ozempic and other anti-obesity drugs is made possible by Medicare negotiation

, which Democrats passed with no Republican support,” said Sen. Ron Wyden (D-Ore.), in a statement.

Wyden added that one of Kennedy’s first actions as HHS secretary was to revoke a plan to allow Medicare to cover these drugs.

In November 2024, the Biden administration had proposed

Medicare and Medicaid coverage of GLP-1 agents when indicated for obesity alone (though not for individuals considered just overweight), but the Trump administration scuttled those plans

. Biden’s proposal was expensive: It would have included coverage for all state- and federally funded Medicaid programs for people with low incomes, costing taxpayers as much as $35 billion over the next decade.

Trump administration officials said the new lower prices also will be provided for state- and federally funded Medicaid programs.

Polls show Americans favor having Medicare

and Medicaid cover the costs. But many insurers, employers, and other bill payers have been reluctant to pay for the drugs, which can be used by a wide swath of the population and can cost hundreds of dollars a month.

One study from last year

found that half of U.S. adults were eligible for semaglutide’s indications, including an estimated 26.8 million insured by Medicare.

Proponents of the coverage have argued that treating obesity can actually reduce longer-term costs by cutting down on heart attacks and other expensive health complications that can arise from the disease.

The benefits consultant Mercer has said that 44% of U.S. companies with 500 or more employees covered obesity drugs last year. More than a dozen state Medicaid programs already cover the drugs for obesity.

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CMS launches pilot to lower Medicaid drug costs: 8 things to know

https://www.beckershospitalreview.com/pharmacy/cms-launches-pilot-to-lower-medicaid-drug-costs-8-things-to-know/

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Final Medicare Physician Fee Schedule Rule Displeases Doc Groups

It “does not go far enough” to address the last two decades of payment cuts, they say

https://www.medpagetoday.com/publichealthpolicy/medicare/118333

Physician groups were generally dissatisfied with the final 2026 Medicare Physician Fee Schedule rule released late last week by the Centers for Medicare & Medicaid Services (CMS).

“Decades of repeated Medicare cuts and rising costs have created an unsustainable situation that is pushing practices, many of whom are small businesses, to the brink of closure and threatening patients’ access to care,” William Harvey, MD, MSc, president of the American College of Rheumatology, said in a statement. “This final rule from CMS does not go far enough to address the 33% decline in reimbursement physicians have faced since 2001. Congress can no longer ignore the damage these chronic underpayments are causing.”

“While we appreciate the modest payment increase finalized by CMS for 2026, this temporary relief does not address the fundamental structural problems plaguing Medicare physician reimbursement,” Jerry Penso, MD, MBA, president and CEO of the American Medical Group Association (AMGA), said in a statement. “The conversion factor increase, driven by a one-time congressional intervention, provides a short-term reprieve, but the underlying erosion of physician payment continues to threaten access to care and the viability of high-value, team-based medicine.”

The new fee schedule gives doctors treating Medicare patients a 3.77% pay bump if they participate in alternative payment models (APMs), and a 3.26% increase for those not participating in APMs. The bulk of those percentages comes from a 2.5% 1-year increase Congress passed in its “One Big Beautiful Bill” in July, as well as a 0.49% adjustment CMS said was necessary to account for proposed changes in work relative value units (RVUs) for certain services. Without those additions, the conversion factor increases would be 0.75% for physicians participating in APMs and 0.25% for those not participating in them.

ATA Action, an advocacy group for telemedicine providers, said in a statement that although it was encouraged by the agency’s inclusion of provisions that expand telemedicine coverage and streamline processes related to it, “we have ongoing concerns that the issue of provider location and home address reporting has not yet been fully resolved, a change that could significantly impact providers across the country when the current flexibility expires on December 31.”

On the other hand, said ATA Action executive director Kyle Zebley, “CMS did finalize an important provision that was not included in the proposed rule that we advocated for, which permanently allows teaching physicians to supervise residents virtually, when the patient, resident, and supervising clinician are in separate locations, in all teaching settings.”

In contrast to the specialists’ groups, the primary care groups sounded more upbeat. The American Academy of Family Physicians (AAFP) said in a statement that it was “pleased by several provisions in the 2026 Medicare Physician Fee Schedule that strengthen the healthcare system and prioritize primary care.”

The provisions cited by AAFP include broadening the use of the G2211 add-on code, which will make it more feasible for doctors to provide care at home, and the introduction of optional add-on codes to support behavioral health integration services.

Unlike the AMGA, the AAFP was positive about the overall payment increases of 3.77% and 3.26%, depending on whether or not the physician is in an APM. “These updates reflect CMS’ commitment to supporting primary care,” the organization said. “However, most of the increases for 2026 are temporary adjustments … which will expire at the end of 2026. To sustain this progress, we urge Congress to take action to prevent another payment cliff, which would leave practices struggling to keep pace with inflation despite the promising direction set by CMS.”

The final rule also included a new “efficiency adjustment” — a 2.5% cut for clinical services that are not time-based — to reflect its opposition to the American Medical Association’s (AMA) longstanding method for recommending physician reimbursement rates using RVUs that are partly based on the amount of time it takes to provide a particular service.

“Research has demonstrated that the time assumptions built into the valuation of many [Physician Fee Schedule] services are … very likely overinflated,” CMS said in a fact sheet about the final rule. The AMA said the efficiency adjustment would reduce payment for 7,000 physician services, amounting to some 95% of all those provided by physicians.

The efficiency adjustment received mixed reviews. “Physicians are already stretched thin by increasingly complex patients and the escalating costs of running a practice,” Qihui “Jim” Zhai, MD, president of the College of American Pathologists, said in a statement. “These reductions to physician work ignore the realities of modern medicine, including rising patient complexity and evolving technologies that demand more from physicians, not less. A one-size-fits-all policy is unfairly targeting pathologists and other specialists.”

The American College of Emergency Physicians also expressed unhappiness. “Unfortunately, the efficiency adjustment for non-time-based services as finalized is a flawed and overly broad policy that fails to differentiate between services that can achieve further efficiencies and those that cannot, as well as those that have already been re-evaluated through existing processes recently,” the group said in a statement, adding that under the new schedule, “independent groups, especially smaller practices, will see shrinking reimbursement while costs remain the same — contracts become financially unsustainable, consolidation accelerates … and emergency department coverage and timely patient access to lifesaving care are put at risk.”

But the American College of Physicians (ACP) disagreed. “ACP is glad to see that the fee schedule finalized the introduction of an efficiency adjustment that will help account for how clinical practices and resource utilization patterns evolve and better align payments with those changes,” ACP President Jason Goldman, MD, said in a statement. He added that the ACP “appreciates CMS’s decision to exclude evaluation and management (E/M) services from the efficiency adjustment. The work associated with E/M services has become increasingly complex and intensive due to the need for comprehensive, person-centered, and relationship-based care.”

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Aren’t politicians suppose to work in the best interest of their constituents ? The Senate has basically shut the federal government down. 

Apparently there is some 2-3 million federal works that are expected to work and not being paid. Of course the 535 members of Congress continue to get paid while the government is “shut down”.

This Saturday, it is claimed that 42 million people who get food stamps – which is now on a EBT debit card -their EBT cards will not be “re-charged” with the $$ that is due the first of the month.   39% of those EBT $$ is for feeding KIDS.  The House has already signed a bill that would provide $$$ to keep the government open for 60-90 days while the Senate works out their problems.

It is claimed it is all over some supplemental $$ for Obamacare premiums, and without it .. some families – 20 million people- will see a $1,200 to $1,800 increase in their annual premiums.

Just out of curiosity, I checked what our Medicare B & Supplement premiums have changed over the last 5 yrs and those premiums for the two of us has went up abt $4,600 over the last 5 yrs. That is affecting 63 million people on Medicare A&B. That is a 55% INCREASE in FIVE YEARS.

The increases in SS $$ over that same time frame is 23% that would be for the average couple would be $7,300. So the increase in Medicare Part B & supplement would have taken 63% of a couple’s SS overall increase. Remember overall COLA ( Cost of Living Adjustment) during the 2020-2024 was abt 20%.

A couple having a $500,000 retirement “nest egg” would have lost $100,000 buying power of the money in their retirement nest egg.

I saw one <D> Senator on TV saying that with the <R> have the White House, majority in the House & Senate, that depriving federal employees of their paychecks – and expecting them to work and depriving 42 million people (39% kids) going  without the ability to purchase food/nutrition. Is the only lever that the <D> have to get the Senate to agree to spend a couple of TRILLION DOLLARS more than we have and would be added to our already 37 trillion national debt.

It is reported that the Senate – which needs a 60% vote in order to keep all of these benefits flowing – has voted THIRTEEN TIMES NO!.

All it would take is 8 <D> to vote to re-open the Federal government.

“The moral test of a government is how it treats those who are at the dawn of life, the children; those who are in the twilight of life, the aged; and those who are in the shadow of life, the sick and the needy, and the handicapped.” – Hubert Humphrey, VP, Pharmacist

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