Trump Admin Using AI to Deny Medical Care for Seniors in Disastrous Experiment — Report

Not long after, media outlets began relaying the disastrous outcomes: technical difficulties, long delays in decisions and care, puzzling denials, frustrated doctors, and patients suffering in pain. Those reports were largely confirmed earlier this month when the Electronic Frontier Foundation released a tranche of federal documents about the program, called WISeR, that the group obtained amid litigation. The documents included feedback from healthcare providers, including one who called the program “a disgrace to the human race” and reported seeing patients crying in pain as they waited for care. Amid the worrying reports, lawmakers have been trying to get answers and shut the program down. 

Meanwhile, the Government Accountability Office determined in May that Trump officials did not follow proper procedure in setting up the programme, calling its legality into question. Still, it appears to be moving ahead unabated, with plans to expand in the years to come. Last week, Rep. Suzan DelBene (D-Wash) called a committee vote to try to get the Trump administration to release more documents about WISeR, but Republicans voted the effort down. “It’s clear why the administration is doing everything they can to conceal these documents. The more that Americans learn about WISeR, the more outraged they get at the Trump administration for jeopardising their care and trying to privatise Medicare,” DelBene said in a statement. 

Technical fumbles WISeR, which stands for Wasteful and Inappropriate Service Reduction, aims to use AI and machine learning to ensure “appropriate Medicare payment” for select services while benefiting taxpayers “by decreasing fraud, waste and abuse.” It was rolled out in January in six states—New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington—and intends to run until the end of 2031. So far, the programme requires prior authorisation for around a dozen medical services, including nerve stimulation, epidural steroid injections for pain, cervical fusions (permanently connecting bones in the neck), skin substitutes for wounds, and treatments for incontinence and impotence. 

According to the documents released by the EFF, the programme’s implementation was rushed, and the technology wasn’t ready. One vendor, Innovaccer, was so unprepared that it asked the government to delay the rollout, and when it didn’t, the vendor set up its program to automatically approve all requests temporarily. “[A]uto-affirming is the only path available that avoids creating a backlog of unprocessed prior authorizations and claims while we finalize, validate, and deploy the full rules-based solution,” Innovaccer wrote, according to a letter it sent to government officials. But others carried on. 

One vendor, Zyter, had data discrepancies for months because it apparently didn’t understand the difference between Medicare Part A, which covers inpatient/hospital care, and Part B, which covers outpatient services. Zyter’s chief executive officer, Sundar Subramanian, told Ars Technica in a written statement that the company is now “fully functional across Medicare Part A and Part B claims.” The company is working closely with federal partners and the healthcare providers to “enhance the experience,” Subramanian said. More denials than approvals Another vendor, Virtix, was found to be denying more prior authorization requests than it was approving. 

According to a weekly report on March 30, Virtix had reviewed 6,096 pre-authorization requests. It approved 2,863 of them, denying 3,233 (53 percent). In addition to a questionable number of denials, decisions from the various contracted companies often took too long. WISeR is intended to provide authorization decisions within 72 hours, but many have taken weeks, some even months. The documents from EFF reveal at least one request was still pending after 83 days. In a survey, one healthcare provider said it “had a surgery pushed back almost two months due to zero communication.” It was revealed in June that Virtix was put on a Corrective Action Plan (CAP) by the Centers for Medicare & Medicaid Services (CMS) for “noncompliance” with the 72-hour window. 

In a statement to Ars Technica, Virtix confirmed it was on a CAP but said it has since “reduced its average turnaround time for prior authorization to 1.18 days and prepayment review determinations to 1.17 days, well within the WISeR Model’s 3-day requirement.” Virtix said the CAP ended on August 14. It’s unclear if any other vendors have been put on a CAP. The CMS and the Department of Health and Human Services did not immediately respond to Ars Technica’s request for comment and a list of questions related to WISeR in time for publication. 

In its comment to Ars, Virtix said that it “understand[s] that any delay in care is difficult for patients, and we do not take lightly the impact that the prior authorization process can have on people who are in pain and seeking relief.” That said,” the company continued, “the WISeR program uses long-established [National Coverage Determinations] and [Local Coverage Determinations] set by CMS, not by Virtix Health, to evaluate the medical appropriateness of each requested procedure.” Virtix encouraged providers to consider resubmitting authorization requests and ask for peerto-peer discussion about denials. “A disgrace to the human race” The suggestion to reach out for support is unlikely to assuage many providers who have experience with WISeR. 

From their perspective, technical snags, delays, and unexpected denials have led to real misery, and many providers have reported only radio silence from program vendors when they sought support. The reality of WISeR’s implementation may best be captured by feedback from one healthcare provider in Ohio, which was working with Innovaccer, the vendor that initially auto-approved requests. In a survey response, the provider wrote (in all capital letters) about patients trying to get a minimally invasive surgery to treat compression fractures in their spines, saying: I HAVE HAD TO WATCH 3 PATIENTS CRY AT BEDSIDE FOR NOT HEARING BACK ON THEIR PRIOR AUTH FOR KYPHOPLASTY/VERTABRAL AUGMENTIATION PROCEDURE. THESE PATIENTS ARE IN DEEP PAIN. SO MANY OFFICES OF MY PHYSICIANS ARE NOT HEARING BACK FROM INNOVACCER… THERE IS NO WAY TO GET A HOLD OF A HUMAN TO TALK TO… WHAT A DISGRACE TO THE HUMAN RACE IN AMERICA. THIS IS THIRD WORLD. 

Another Ohio provider expressed similar frustration with Innovaccer about delayed care and lack of communication, writing in a survey response that the experience has been “extremely disappointing”: A 3–4 day delay for necessary pain procedures is already difficult for vulnerable patients, but when providers cannot obtain answers for weeks, the situation becomes unacceptable… The lack of accessible support, accountability, and timely communication is deeply concerning. Programmes affecting patient access to medically necessary procedures must have reliable provider support systems. Currently, that standard is not being met. Patients deserve better. Providers deserve answers. And systems designed to improve care should never result in preventable suffering.