The test will involve the Centers for Medicare and Medicaid Services using Artificial Intelligence to make prior authorization decisions on procedures like using skin and tissue substitutes, electrical nerve stimulation implants, arthroscopic surgery for osteoarthritis and the like.
Twila Brase of Citizen's Council for Health Freedom says AI is about to change medicine in a big way.
“There is a plan to use Artificial Intelligence at a lot of different levels within the patient/doctor relationship, and within medical decision making, hospital decisions, all of that.”
She says effectively that will mean that CMS can increase the number of prior authorizations needed for procedures from one in a hundred to around two per enrollee without increasing the cost or efficiency.
“AI is being looked at the way that it's going to increase efficiency and decrease cost, but I'm not sure that it's going to feel that way to patients.”
AI has made a significant impact in the workforce, education, health care and beyond. While some remain hesitant about its usage and the possibility of it eliminating human jobs, AI tools have been linked to greater efficiency for many companies.
But the healthcare landscape is different.
Brase says the more prior authorizations that are required, the more procedures will be denied. She says there's a financial incentive as well.
“I think it is a concern that the government is coming in, that the government is using staff who will be paid more with every denial that they provide, and that they will be using AI as the rationale for why they have decided to deny care.”
The economic component
The move toward AI arrives as the Trump administration has made it a priority to reduce government fraud and waste, and Medicare Part B premiums are likely to increase by $21.50 per month, from $185 in 2025 to $206.50 in 2026, according to MarketWatch.
She says no matter how efficient AI is, or will become, it cannot account for individual needs like a doctor can.
“Individuals are very different in what they can tolerate, what their DNA is like. You can have all sorts of claims about how something will work or not, but then it doesn't necessarily work for the individual because the individual is so unique.”
