2026年6月23日 美国东部时间早上5:00 / KFF健康新闻
65岁的比尔·库里在俄克拉荷马州农村的土地上养牛，这片土地曾属于他的父亲和更早的祖辈。多年来，每季度他都会驱车两个半小时前往俄克拉荷马城，接受脊柱硬膜外注射以治疗背痛。
但今年，由于一项新的医疗保险计划，他不得不更频繁地奔波。
今年2月的一次就诊中，他意外得知该治疗需要提前审批。大约一个月后，他再次前往医院注射，往返路程总共耗时10小时。诊所甚至要求他第三次前往，这是此前从未有过的要求。库里说，那次预约“只是为了填一张表，再次告知医生自己的感受”，因此他并未前往。
今年1月，俄克拉荷马州成为六个开始试点传统医疗保险提前审批项目的州之一，该联邦医保项目面向65岁以上老年人或残障人士。此前，医疗保险一直避免采用这种被称为“预先授权”的做法，即要求患者或其医疗团队在进行某些手术、检查和开药前，先获得保险公司的批准。
库里接受的硬膜外注射是受新计划监管的13项医疗服务之一，特朗普政府称这类服务存在欺诈或滥用风险。该项目名为“减少浪费和不当服务模式”（简称WISeR），由人工智能驱动，旨在为联邦政府节省开支，并保护患者免受潜在不安全或不必要的治疗。
然而，俄克拉荷马州和其他试点州——亚利桑那州、新泽西州、俄亥俄州、德克萨斯州和华盛顿州——的早期反馈显示，WISeR的推行并不顺利。接受KFF健康新闻采访的患者、医生和其他医疗专业人士表示，该项目造成了混乱、差错、漫长的等待时间和压力。有人将此次推行描述为“极其糟糕”，并称试点州的医疗保险参保者如今陷入了和私人保险参保者一样的繁文缛节中。
一个核心担忧是项目推进过于仓促。WISeR于2025年6月宣布，并于1月中旬启动。
“这比联邦政府的正常节奏快得多，”俄亥俄州医学协会最近卸任的首席执行官托德·贝克说道。华盛顿州医学协会政策主任杰布·谢泼德补充道，医生们“基本上只能自己摸索”。
政府承包商也承认了此次快速推行的情况。“从接到通知到上线，我们的推广节奏非常紧张，”负责俄克拉荷马州项目的Humata Health公司首席执行官杰里米·弗里斯说道。为其他州提供服务的科技高管表示，他们甚至在今年春季还在为产品添加功能。
负责管理该项目的医疗保险和医疗补助创新中心主任艾贝·萨顿未就推行时间表置评。但他在一份声明中表示，这些改革的目标是确保预先授权流程高效、快速且简化。
“该模式旨在减少不当医疗，同时不延误必要的治疗，”他说道。
医疗保险和医疗补助服务中心负责人穆罕默德·奥兹去年12月在接受《新闻国家》采访时表示，他们正在“针对滥用行为推行部分预先授权措施”。
“这些措施的目的不是拒绝治疗，”奥兹继续说道，“而是确保你获得需要且应得的治疗，而非某些无良医生想强加给你的治疗。”
近年来，医疗保险一直面临与特定服务相关的疑似欺诈问题。美国卫生与公众服务部监察长去年9月警告称，例如，该项目在皮肤替代用品上的支出在两年内飙升近700%，“引发了对欺诈、浪费和滥用的重大担忧”。皮肤替代用品是目前受WISeR审查的13种疗法之一。
该项目还对椎体后凸成形术（一种治疗脊柱骨折的手术）施加了预先授权要求，医疗保险支付咨询委员会的一份报告指出该手术存在过度使用的情况。
不过萨顿承认，“存在浪费、欺诈和滥用行为的医疗机构比例很小”。
消费者和临床医生大多厌恶预先授权流程。尽管联邦卫生官员正在为医疗保险测试该流程，特朗普政府却正试图为私人保险参保者缩减这一流程。根据KFF今年1月的一项民意调查，69%的参保成年人认为预先授权给治疗带来了负担。
通过WISeR，医生及其工作人员登录在线门户提交证明治疗合理性的医疗记录。Humata公司首席执行官弗里斯告诉KFF健康新闻，系统利用人工智能快速批准符合项目标准的申请。他表示，在临床数据支持批准的案例中，有88%会“立即通过”。
医疗保险和医疗补助服务中心吹嘘该流程可在72小时内给出决定。之后，临床医生会收到一个“通用跟踪编号”，以便安排治疗并获得报销。但实际上，参与者表示该流程绝非易事。
根据美国参议员玛丽亚·坎特韦尔（D-华盛顿）办公室4月发布的一份利用医院协会数据撰写的报告，仅华盛顿大学医疗系统今年初就有近100名患者因WISeR相关延误等待硬膜外注射。“如今，患者面临着WISeR模式实施前不存在的延误或拒付，”报告称。
俄克拉荷马州的养牛户库里表示，他未来可能会前往堪萨斯州接受治疗，以避开审批流程。新泽西州的物理医学与康复医生多洛塔·格里宾表示，她的一名患者需要接受背痛治疗，等到授权获批时，患者已经去医院接受了更昂贵的治疗。
俄克拉荷马州临床放射科的预认证和保险主管詹妮弗·巴列表示，在椎体后凸成形术方面，审核员提出了大量“吹毛求疵”的要求。她说，还有其他时候，诊所提交给医疗保险和医疗补助服务中心的信息被忽视，审核员会要求提供文件中已有的影像学资料。
俄克拉荷马州塔尔萨的肌肉骨骼放射学家詹姆斯·韦伯表示，本应无问题的索赔应在15天内获得支付，但他对椎体后凸成形术的预先批准和报销流程感到沮丧。“我们看到的是6到8周的延误，”他说道。
“情况极其糟糕，”凤凰城地区的疼痛管理医生杰里·索贝尔说道，“从一开始就毫无章法。”索贝尔表示，截至5月，他还未收到9次硬膜外注射的医保报销款。
“我们持续监控运营，并与利益相关者密切合作，解决疑问、改善服务提供者的体验，”负责亚利桑那州项目的Zyter公司首席执行官桑达尔·苏布拉马尼亚姆说道。
在4月的一次网络研讨会上，Zyter的另一名高管承认存在大量积压至1月的付款案件。医疗保险的萨顿表示，这些积压“目前正在解决”，但未提供更多细节。
当被问及其他问题——包括医生怀疑是人工智能驱动的差错时，医疗保险的萨顿表示，该机构感谢“关于服务提供者体验的反馈”。他表示，这些反馈将用于“帮助服务提供者更好地理解WISeR流程”。
尽管医疗保险和医疗补助服务中心的供应商表示，最终的批准决定由人类做出，但医生及其工作人员认为，人工智能在该流程中发挥了重要作用，拒付有时是人工智能“幻觉”导致的，即篡改或编造信息。
一名未获执业机构授权发言的亚利桑那州医生回忆称，系统拒付的理由是他的患者不符合胸部区域（即中背部）手术的资格，但该患者实际需要接受颈部注射。俄克拉荷马州的放射学家韦伯记录了四次患者没有麻木感的情况，但他的WISeR申请仍被拒，理由是“麻木”，审核员认为这会排除脊柱手术的可能性。
Humata公司首席执行官弗里斯表示，他从未听说过人工智能幻觉的情况。
该流程也在推高政府成本。随着拒付数量增加，向医疗保险行政承包商提起的上诉也越来越多。政府向承包商支付处理上诉的费用，医疗保险的萨顿承认，该机构已经“考虑到了WISeR项目及其相关成本导致的医疗保险上诉数量潜在变化”。
根据美国全国保险专员协会2025年发布的一项调查，84%的商业保险公司已经在使用人工智能工具，尽管他们一直表示人工智能不会被用于拒绝预先授权申请。
医疗保险中人工智能的使用可能会给该项目带来摩擦和挫败感，并增加参保者的成本。研究该技术的匹兹堡大学卫生政策研究员米兰达·亚弗表示，预先授权为保险公司节省资金的部分原因，是让患者在等待时间和不便方面付出代价。
“人们最终会陷入大量繁文缛节，不得不长时间等待、被反复转接，”她说道。她常常怀疑，预先授权只是将成本转嫁给患者和医生，而非真正节省开支。
一些参与医疗保险预先授权试验的医生认为，该项目不可避免地会超出华盛顿官员认定的易欺诈服务范围。
“每个人都知道，如果这个试点项目成功，基本上所有手术都将需要预先授权，”俄克拉荷马州斯蒂尔沃特的家庭医生玛丽·克拉克说道，“如果他们能证明可以节省资金，那么这一经验将被推广到其他手术以及其他州的多项其他服务中。”
当被问及医疗保险和医疗补助服务中心是否考虑扩大预先授权试点范围时，萨顿在声明中表示，目前“没有任何变更”计划调整受WISeR项目监管的服务清单，但“医疗保险和医疗补助服务中心将持续评估是否有必要进行任何变更”。
你是否有过预先授权的相关经历想要分享？点击这里向KFF健康新闻讲述你的故事。
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https://www.youtube.com/watch?v=as0I7eL0F74
Medicare’s AI push snarls patients and doctors in errors and delays
June 23, 2026 5:00 AM EDT / KFF Health News
Bill Curry, 65, raises cattle on the same land in rural Oklahoma once owned by his father and generations before him. Each quarter, for several years, he has made the 2½-hour drive to Oklahoma City for an epidural in his spine to treat his back pain.
But this year, because of a new Medicare program, Curry has traveled a little more often.
In February, during one trip, he was told unexpectedly that he needed preapproval for the procedure. Then he went again a month or so later to get the injection, for a total of 10 hours on the road. His clinic wanted him to come in a third time, which they had never asked of him before. That appointment was “just to fill out a piece of paper to tell them how you feel again,” Curry said, so he hasn’t gone.
In January, Oklahoma became one of six states to begin a pilot program testing the use of preapprovals in traditional Medicare, the federal health insurance program for people 65 and older or with disabilities. Medicare had previously eschewed the practice — also known as prior authorization — which requires patients or someone on their medical team to seek insurance approval before proceeding with certain procedures, tests, and prescriptions.
Epidurals like Curry’s are among 13 medical services subject to the new program because the Trump administration says they’re prone to fraud or misuse. Powered by artificial intelligence, the program — called the Wasteful and Inappropriate Service Reduction Model, or WISeR — is intended to save the federal government money and protect patients from potentially unsafe or unneeded care.
Yet early reviews from Oklahoma and the other pilot states — Arizona, New Jersey, Ohio, Texas, and Washington — suggest WISeR’s rollout has not been smooth. Patients, doctors, and other healthcare professionals who spoke with KFF Health News say the effort has created confusion, errors, long wait times, and stress. Some described the rollout as “horrendous” and say people enrolled in Medicare in the pilot states are now getting ensnared in the same red tape as those with private insurance.
One key concern is that it all happened too hastily. WISeR was announced in June 2025 and launched in mid-January.
That was “quicker than normal” for the federal government, said Todd Baker, who recently stepped down as CEO of the Ohio State Medical Association. Doctors “just sort of had to figure it out,” added Jeb Shepard, director of policy at the Washington State Medical Association.
Government contractors have also acknowledged the rapid pace. “We’ve had an aggressive rollout from the time of being notified to going live,” said Jeremy Friese, CEO of Humata Health, the vendor for Oklahoma. Tech executives servicing other states have said they were still adding features to their products in the spring.
Abe Sutton, director of the Center for Medicare and Medicaid Innovation, which is administering the program, didn’t comment on the rollout schedule. But he said in a statement that the goal of these reforms is to ensure that prior authorization is efficient, fast, and streamlined.
“The model aims to reduce inappropriate care without delaying appropriate care,” he said.
Mehmet Oz, the leader of the Centers for Medicare & Medicaid Services, told NewsNation in December that they were “rolling out some prior authorization on abused practices.”
“The purpose of these is not to deny care,” Oz continued. “It’s to make sure you get the care you need and deserve, not the care some unscrupulous doctor wants to use on you.”
Medicare has struggled in recent years with suspected fraud associated with particular services. The Department of Health and Human Services’ inspector general warned in September that the program’s spending on skin substitutes, for example, had surged nearly 700% over two years, raising “major concerns about fraud, waste, and abuse.” Skin substitutes are among the 13 therapies currently subject to review under WISeR.
The program also imposes prior authorization requirements for kyphoplasty, a surgery for spinal fractures, which a report by the Medicare Payment Advisory Commission flagged as overused.
Sutton acknowledged, however, that “the percentage of providers committing waste, fraud, and abuse is small.”
Consumers and clinicians largely detest prior authorization. Even as federal health officials test the process for Medicare, the Trump administration is trying to scale it back for those with private insurance. According to a KFF poll conducted in January, 69% of insured adults consider prior authorization a burden for care.
Through WISeR, doctors and their staff log in to online portals to submit medical records that justify the procedures. Using artificial intelligence, the systems quickly approve applications that meet the program’s criteria, Friese, Humata’s chief executive, told KFF Health News. He said there is an “immediate yes” in 88% of cases for which clinical data supports an approval.
CMS has touted the process as one in which decisions are returned within 72 hours. After that, clinicians receive a “universal tracking number,” which allows them to schedule the procedure and get paid. In practice, however, participants say the process is anything but easy.
The University of Washington’s medical system alone had nearly 100 patients waiting earlier this year for epidural injections due to WISeR-related delays, according to an April report from the office of U.S. Sen. Maria Cantwell (D-Wash.) that drew on hospital association data. “Now, patients are subject to delays or denials which did not exist prior to the WISeR Model,” the report said.
Curry, the Oklahoma cattle farmer, said he might go to Kansas for future treatments to avoid the approval process. Dorota Gribbin, a New Jersey-based physical medicine and rehabilitation physician, said that by the time authorization came for one of her patients who needed a back pain procedure, the patient had gone to the hospital for more expensive care.
Jennifer Valle, a precertification and insurance supervisor at Clinical Radiology of Oklahoma, said when it comes to kyphoplasties, there has been a lot of “nitpicking” from reviewers. Other times, information her practice provides to CMS gets overlooked, she said, and reviewers ask for imaging that’s already in the file.
Claims with no problems are supposed to be paid within 15 days, said James Webb, a musculoskeletal radiologist in Tulsa, Oklahoma, who has also been frustrated by the prior approval and reimbursement process for kyphoplasties. “Six- to eight-week delays is what we’ve been seeing,” he said.
“It’s been horrendous,” said Jerry Sobel, a Phoenix-area pain management doctor. “Right from the beginning, there seemed to be no organization.” Sobel said that as of May, he hadn’t gotten paid by Medicare for nine epidurals.
“We continuously monitor operations and work closely with stakeholders to address questions and improve the provider experience,” said Sundar Subramanian, the CEO of Zyter, which has the contract for Arizona.
During an April webinar, another Zyter executive acknowledged a large backlog in payments stretching to January. Those backlogs “are currently being resolved,” Medicare’s Sutton said, without providing further detail.
When asked about other issues — including what doctors suspect are AI-driven errors — Medicare’s Sutton said the agency appreciates “feedback on provider experience.” It will be used “to help providers better understand WISeR processes,” he said.
Although CMS vendors say humans make the final decisions on approvals, doctors and their staffs believe artificial intelligence is playing a large role in the process and that denials are sometimes the result of AI hallucinations that garble or make up information.
One Arizona doctor, who wasn’t authorized by his practice to speak, recalled a denial saying his patient wasn’t eligible for procedures in the thoracic region, or mid-back. The patient needed an injection to the neck. Webb, the Oklahoma radiologist, documented four times that a patient lacked numbness, and yet his WISeR application was still denied, citing numbness, which, in the reviewer’s interpretation, would rule out the spinal surgery procedure.
Friese, Humata’s CEO, said he hasn’t heard about any AI hallucinations.
The process is also raising government costs. With more rejections, more appeals are being filed with Medicare’s administrative contractors. The government pays the contractors to handle the appeals, and Medicare’s Sutton acknowledged that the agency has “accounted for potential changes in the volume of Medicare appeals because of the WISeR program and its associated costs.”
Eighty-four percent of commercial insurers already use AI tools, according to a survey released in 2025 by the National Association of Insurance Commissioners, though they have consistently said AI isn’t used to deny prior authorization requests.
Its use in Medicare risks introducing friction and frustration into the program — and piling costs onto its beneficiaries. Prior authorization saves money for insurers partly by making patients pay a price in wait times and inconvenience, said Miranda Yaver, a University of Pittsburgh health policy researcher studying the technique.
“People will end up getting ensnared in a lot of red tape, having to be on hold, and getting rerouted,” she said. She often wonders whether prior authorization simply shifts costs to patients and doctors, rather than saving them.
Some doctors involved in Medicare’s prior authorization experiment believe it will inevitably expand beyond a few services officials in Washington consider fraud-prone.
“Everybody knows that if this pilot project works, it will be prior auth for basically all procedures,” said Mary Clarke, a family practice physician in Stillwater, Oklahoma. “If they can show that they can save money, then that’s going to be extrapolated and rolled out to other procedures and multiple other things in other states.”
When asked whether CMS is considering expansion of its prior authorization pilot, Sutton said in his statement that there are “currently no changes” considered for the list of services subject to the WISeR program, “but CMS continues to assess whether any changes are warranted.”
Do you have an experience with prior authorization you’d like to share?Click here to tell KFF Health News your story.
KFF Health News Southern correspondent Lauren Sausser contributed to this report.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.
https://www.youtube.com/watch?v=as0I7eL0F74
