Introduction to the Issue
Rep. Lois Frankel told Floridians on Friday she is pushing back against a national movement to add prior-authorization requirements to Medicare and to use algorithms to override doctors’ judgment in medical treatment.
On Jan. 1, the U.S. Centers for Medicare & Medicaid Services launched a pilot program in six states that contracts with private companies to use artificial intelligence to make prior-authorization decisions for Medicare coverage of certain treatments. The pilot program aimed at eliminating wasteful spending in healthcare is called the Wasteful and Inappropriate Service Reduction Model. It requires providers to obtain approval before performing specific procedures such as care for Parkinson’s disease and other tremors, chronic pain, sleep apnea, wound care, and incontinence. Florida is not one of the six states included in the pilot program that will run through Dec. 31, 2031.
Concerns About the Pilot Program
“We are worried because pilot programs start in a few places and then it spreads,” Frankel, a South Florida Democrat, said Friday at a news conference at the Mandel Public Library in West Palm Beach on Friday,. “With my like-minded colleagues, we are fighting back. We have all kinds of efforts to stop the funding and legislation to make it illegal. We believe Medicare is based on a promise that if a doctor says you need care, Medicare will be there for you, not AI.”
Legislative Actions
Six House Democrats introduced legislation in November to shut down the pilot. In addition, Frankel has introduced an amendment in a 2026 spending bill that blocks funding for the pilot program.
Impact on Seniors
In Palm Beach County on Friday, Frankel said that seniors pay into Medicare their entire lives and rely on it for healthcare coverage. If Medicare requires prior authorization, it would delay care by forcing seniors to wait for their insurance to approve a treatment their doctor knows they need, she said, adding that she opposes using AI in this way. “AI needs to be a tool for the doctor, the doctor should not be a tool for AI, nor should AI be used as a weapon to deny care,” Frankel said.
Medical Professionals’ Perspectives
Dr. Andrew Rosenthal, a Boynton Beach plastic surgeon, said Medicare was designed around the trust of physicians, relying on them to know what’s best for a patient’s care. With wound care and skin tears, an area especially important for seniors, allowing doctors to move quickly and use their expertise is critical, he said Friday. Rosenthal said quick decisions about the use of skin substitutes often prevent people from ending up in the hospital, needing amputations, getting infections, and landing in the ER.
Patient Concerns
“I may want to use something on a wound, but if I have to wait for prior approval, that means the patient could have to wait days or months to get that treatment, and in the meantime, that wound is going to get worse, and it’s harder to treat,” he said.
Joan Waitkevicz, a retired physician, said she sees the disadvantages of the original Medicare prior authorization pilot program from all angles. As a provider, she has seen how much time prior approval takes, time that could be spent with patients. As a Medicare recipient, she sees it as a means to disqualify people from care. “How much money is going to be shelled out to the AI companies that could be going into care?” she asked at Frankel’s news conference.
Personal Stories
Medicare recipient Iris Smith said she goes to the gym and plays golf regularly, and now has arthritis in both hands. “My doctors know me and I know my doctors. When I am in pain, I need something to take care of the pain,” she said. “I don’t need to see a doctor or AI to diagnose me because my doctor has already done it. He knows what to prescribe. I don’t need to wait. I can’t wait when the pain is bad.”
Conclusion
Frankel said she believes many seniors enrolled in Medicare aren’t yet aware of the pilot program.
“We are trying to stop it,” she said. “There are millions of people on Medicare who could find themselves going to a doctor in pain, and the doctor saying, ‘Sorry, I can’t give you a treatment until Medicare approves this.’”
FAQs
Q: What is the Wasteful and Inappropriate Service Reduction Model?
A: The Wasteful and Inappropriate Service Reduction Model is a pilot program launched by the U.S. Centers for Medicare & Medicaid Services to use artificial intelligence to make prior-authorization decisions for Medicare coverage of certain treatments.
Q: Which states are included in the pilot program?
A: The pilot program is being tested in six states, although Florida is not one of them.
Q: What are the concerns about the pilot program?
A: The concerns include delayed care, the use of AI to override doctors’ judgment, and the potential for AI companies to profit from the program at the expense of patient care.
Q: What actions are being taken to stop the pilot program?
A: Six House Democrats have introduced legislation to shut down the pilot, and Rep. Lois Frankel has introduced an amendment to block funding for the program.
