Washington Medicare registrants may need to get additional approval immediately before they can take some medical procedures.
The six-year pilot program began on January 1 in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington, and relies on artificial intelligence to determine whether certain care is covered by compensation.
While doctors are voluntary to participate, critics still view the initiative as a sign that the Trump administration is creeping up towards Medicare privatization, and it is volatile by the use of AI.
“This is disappointing and surprising news,” said Dr. Matt Hollon of the Washington Medical Association. “Patients expect care to be guided by doctors, not by insurance companies or automated systems.”
The Centers for Medicare and Medicaid Services in the United States say the goal is to eradicate fraud, waste and abuse with Medicare, a federal program that provides health insurance to people over the age of 65 and young people with disabilities.
Washington state patient advocates, doctors, hospitals and lawmakers argue that the current form of process known as advance permitting has become frustrating and has created a barrier to care.
And they say they got most details from the federal government in a rapid development.
For one, it is unclear why Washington was chosen.
The Center for Medicare and Medicaid Services spokespersons said state inclusion reflects the agency's “goal of testing across diverse practice environments to ensure reliable and valid model testing.” Washington has around 1.6 million Medicare beneficiaries, about half of whom are registered with traditional Medicare, and the other half are registered with Medicare Advantage.
Known as wasteful and inappropriate service reduction, or wise, the new model works with third-party companies deploying artificial intelligence to determine whether traditional Medicare enrollees are eligible for a particular outpatient procedure. Healthcare professionals need to confirm the denials that AI technology makes.
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The applicable procedures are those the federal government sees as too expensive for the resulting medical benefit, or lack of it. They include skin and tissue alternatives, impotence treatment, deep brain stimulation, cervical fusion, and knee arthroscopy, including osteoarthritis. For example, spending on expensive skin substitutes has skyrocketed in recent years despite the clinical value being questioned.
A CMS spokesperson said the goal is to “help patients avoid unnecessary and inappropriate procedures in a narrow set of services.” However, critics are worried that this will open the door to expanding practice to other procedures, perhaps during the six-year pilot. They also argue that it could be a step towards privatization.
D-Wash. Senator Patty Murray called it “privatizing Republican healthcare and letting AI decide who is worthy of healthcare.”
“I'm going to oppose every way I can in the Senate,” Murray said in a statement.
The third-party companies involved fear that they will be compensated for the percentage of savings they generate and that decision makers will be encouraged to refuse approval.
“The use of AI is considering aggregation of this type of data. It is not the case for individual patients, and may not be aware of the individual situation, and is then paid to deny care,” says Hollon, a doctor at Spokane. “That's against healthcare.”
A CMS spokesperson said businesses faced penalties for illegal denials and late decisions.
The doctor will volunteer to submit a prior permission request. Otherwise, their claims will be subject to traditional prepayment reviews. The incentive for a doctor is knowing that instead of learning after the fact that it is not covered, your care is compensated in advance.
Jeb Shepherd, the Medical Association's Policy Director, sees this as a “first foray” into traditional Medicare advance approval, and may not necessarily be voluntary.
Related: Oregon's largest Medicaid provider on how Trump's megaville will affect state health insurance
How did it work before?
Medicare's advantages, including Medicare approval plans from private insurers, have already rolled out prior permissions, in contrast to traditional Medicare, which are rarely needed.
Most refusals of pre-approval under the Medicare advantage have been overturned at the time of appeal. However, some patients don't even know they can appeal and don't even abandon their care.
Scrutiny over prior approval has increased after the murder of United Healthcare CEO Brian Thompson last year.
Companies participating in the new process may overlap with companies already involved in Medicare Advantage's unpopular review system.
A few days before launching the wise model in June, Health and Human Services Secretary Robert F. Kennedy Jr. and CMS administrator Mehmet Oz promoted pledges from industry leaders to streamline and reduce prior approvals in Medicare advantage.
President Donald Trump will be listening as the Center for Administrators of Medicare & Medicaid Services, speaking on Monday, September 22nd, 2025 at the Roosevelt Room in Washington in the Roosevelt Room in the White House.
Mark Schiefelbein / AP
The insurance company said it had erased the delays that wanted patients and doctors when it wanted to determine 80% of requests within the instant by 2027.
“Hospitals are not opposed to the idea of ensuring that the care they are provided is the care they need,” said Taya Briley, a general counsel with the Washington State Hospital Association. “What hospitals are worried about is essentially a tedious process that just slows down the system. It makes it difficult for patients to get the care they need and it makes it difficult for hospitals to get paid.”
“Pre-authorization is part of every physician's day-to-day work and adds a lot of time,” said Dr. Bindu Nayak, endocrinologist at Wenatchee Confluence Health. She added that this is the time that she can instead work directly with patients.
Meanwhile, the statewide health insurance benefits advisor program manager at the Washington Insurance Secretary's Office believes that wise men could become “pure positive.”
“If the pilot works as expected, a more definitive YES or NO (if) Medicare will pay faster,” said program manager Tim Smolen. “So it should be less surprising to providers and beneficiaries.”
I'm looking for the answer
Last month, Rep. Susan Delvene of D-Medina led letters from more than dozens of colleagues asking countless questions about the pilot. Washington representatives Marilyn Strickland, D-Tacoma and D-Bremerton Emily Randall also signed on.
As of Monday, Oz had not responded.
“This should be a bipartisan issue. The states are all over the country,” Delvene said in an interview. “There must be concerns about making people accessible to care in all these states, and there must be concerns about understanding exactly how the model works, why it's set up like this, and what the goal is.”
A spokesman for AARP said the organization is “looking closely” at wise implementation.
“We are deeply concerned about the persistent reporting of Medicare fraud and abuse, which is ejecting a system of much-needed resources,” the spokesperson said in an email. “At the same time, health care for older Americans must always come first, and no one should be denied the legitimate treatment they need.”
This year, Washington state lawmakers considered laws that added surveillance to the use of prior approvals and limit the role of artificial intelligence. The measure has not made much progress in Congress, but will return in 2026.
Also, at the federal level, Delvene has pushed for a bipartisan bill, speeding up the existing pre-certification process for Medicare Advantage enrollees and adding guardrails.
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