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Medicare just bet the farm on AI to fix prior authorizations.
On January 1, CMS quietly launched the most ambitious healthcare AI experiment in government history: the WISeR Model.
Six states, New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington, are now guinea pigs for an AI system that decides which Medicare services get approved.
Here’s what’s actually happening:
The government is using machine learning algorithms with human review to analyze prior authorization requests in real-time. The AI identifies potentially wasteful services, flags unusual patterns, and streamlines approvals for routine care.
Think about that for a second.
We’re handing over Medicare gatekeeping decisions to algorithms. The same prior authorization process that denies 2 million Medicare requests annually. The same process that delays cancer treatments, surgeries, and critical medications.
Now it’s powered by AI.
The irony? While 14 major health systems just dropped Medicare Advantage plans citing prior auth nightmares, CMS is doubling down on the very technology insurers use to deny care.
But here’s where it gets interesting:
CMS claims their AI is different. It includes mandatory human oversight. It focuses on reducing waste, not denying care. It promises to speed up approvals for legitimate services.
If this works, we could see authorization times drop from weeks to minutes. Physicians could get instant approvals for routine procedures. Patients could access care without bureaucratic delays.
If it fails? We’ve just automated Medicare denials at scale.
The six-year pilot runs through 2031. That’s 70 million Medicare beneficiaries watching to see if AI becomes their advocate or adversary.
The real question isn’t whether AI can manage prior authorizations.
It’s whether we trust algorithms to decide who gets care.
♻️ Repost if AI should enhance healthcare decisions, not replace human judgment
👉 Follow me, Jonathan Govette, for real-time updates on healthcare technology and business news. LinkedIn Profile: https://www.linkedin.com/in/jonathangovette/
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Author:
CEO/Co-Founder @ Oatmeal Health | AI Lung Cancer Screening | Almost Became a Doctor | Engineer | Follow to Share What I’ve Learned Along the Way
I help patients get the care they need earlier, preventing late-stage cancer.
That’s been the throughline across three companies and almost 20 years in healthcare. At ReferralMD, we fixed broken referral networks so patients didn’t fall through the cracks. At Oatmeal Health, it’s lung cancer: building the diagnostic and screening infrastructure so the 85% of cases caught too late get caught early instead.
Today as CEO of Oatmeal Health, I lead a team embedding AI into radiology workflows to turn routine lung CT scans into reimbursable cancer risk assessments. We partner with FQHCs to reach underserved communities, and with health systems and payers to make early detection economically sustainable. Think HeartFlow or Cleerly, but for lungs.
Between companies, I advised at Techstars and Plug and Play, mentoring founders building in digital health. That experience shaped how I think about what separates companies that ship from companies that stall: distribution, reimbursement, and clinical trust, not just technology.
I’m a CancerX alumnus, a 3x healthcare founder, and someone who believes the biggest problems in cancer aren’t scientific. They’re operational.
We’re hiring mission-driven builders at Oatmeal Health. If you want to work on something that matters, reach out.
When I’m not working, I’m traveling, mentoring, and keeping up with one very energetic husky. 🐾
Substack – The Oatmeal Bite:
Millions of patients get less care because of who they are, where they live, or how they look. I’m fighting to change that. CEO @OatmealHealth, a startup built for the underserved. The Oatmeal Bite: intel for clinicians, investors, and advocates.
Jonathan Govette
CEO of Oatmeal Health
Substack:
https://oatmealhealthjonathangovette.substack.com/
