Key Takeaways
- A federal pilot program in six states uses artificial intelligence (AI) to review prior‑authorization requests for 17 Medicare‑covered procedures, with private contractors paid based on how many claims they deny.
- Senators Patty Murray (D‑WA) and Ron Wyden (D‑OR) and a panel of doctors argue the model delays essential care for seniors, worsening pain, mobility, and mental health.
- Early data show Virtix Health, the contractor in Washington, denied more claims than it approved in the first quarter of 2026.
- Appeals can take months, creating a ripple effect that clogs appointments and adds to patients’ depression and stress.
- Murray introduced a bill to ban AI‑driven reviews by private firms; it was voted down, but she pledged to keep pursuing legislative remedies.
Roundtable Highlights Growing Alarm Over AI‑Driven Prior Authorization
On Friday, Oct. 9, 2026, doctors and Democratic lawmakers gathered in Vancouver, Washington, to voice mounting concern about a new federal pilot program that employs artificial intelligence to evaluate Medicare prior‑authorization requests. U.S. Sen. Patty Murray, a Washington Democrat, opened the discussion by labeling the initiative “outrageous” because its business model financially rewards denials. “When your business model relies on denials, denials are what seniors are going to get,” Murray said, echoing the sentiment of many clinicians who fear the algorithm is putting profit ahead of patient health. The roundtable also featured Sen. Ron Wyden of Oregon and three physicians from local health systems, all of whom warned that the AI tool is systematically blocking access to treatments that seniors rely on for mobility and pain relief.
How the Wasteful and Inappropriate Service Reduction Model Operates
The program, formally titled the Wasteful and Inappropriate Service Reduction Model, went live Jan. 1, 2026, in six states, including Washington, and is slated to run for six years. It delegates the review of prior‑authorization requests for 17 specific procedures—ranging from nerve stimulation and cervical fusion surgery to sleep‑apnea therapies and wound‑care treatments—to private companies that use AI algorithms to decide whether Medicare should pay. According to a press release from the Centers for Medicare and Medicaid Services (CMS), the model aims “to protect American taxpayers by leveraging enhanced technologies … to ensure timely and appropriate Medicare payment for select items and services.” In practice, however, the AI evaluates each request against cost‑saving criteria, often flagging clinically indicated services as unnecessary or wasteful.
Profit Motive Tied to Denial Rates Raises Ethical Questions
A central criticism raised at the roundtable is the contractors’ payment structure: firms such as Virtix Health, which handles Washington’s Medicare claims, receive compensation based on the proportion of claims they deny. Sen. Murray highlighted this conflict of interest, stating, “They are paid a percentage [of] the care they deny.” Internal documents obtained by the Electronic Frontier Foundation revealed that, in the first three months of 2026, Virtix denied more claims than it approved—a statistic that underscores how the financial incentive aligns directly with restricting patient access. Critics argue that this model transforms a safeguard against fraud into a revenue‑driven gatekeeper, potentially sacrificing clinically warranted care for short‑term savings.
Real‑World Harms: Delays in Care for Chronic Pain and Mobility
Physicians described concrete harms stemming from the AI’s denials. Dr. Keren Rosenblum, who practices in Vancouver, Washington, noted that patients whose physicians have recommended treatments such as cervical fusion or nerve stimulation are left waiting while they navigate the appeals process. “These are patients who had their physicians evaluate them and recommend a treatment, but they were left waiting while we had to navigate this complicated administrative review process,” Rosenblum said. She added that each week of delay can translate into disrupted sleep, limited mobility, difficulty performing daily activities, and diminished independence. Leon McCook, a physician with PeaceHealth, echoed these concerns, emphasizing that chronic pain not only reduces mobility but also heightens stress and depression, creating a cascade of worsening health outcomes while patients await approval.
Senators Murray and Wyden Call the Program ‘Outrageous’ and Essential
Both senators framed the issue as a matter of equity and seniors’ wellbeing. Sen. Wyden stressed that the 17 procedures under AI review are “absolutely essential for seniors in order to keep their mobility,” warning that denials threaten the ability of older adults to remain active and independent. Sen. Murray reiterated her legislative push, noting that she introduced a bill in December 2025 aimed at preventing private companies from using AI to review Medicare claims in the pilot states. Although the bill was voted down in committee, Murray affirmed her intention to keep fighting: “I will keep trying to stop this practice because seniors deserve timely, appropriate care, not a profit‑driven denial machine.” Their bipartisan‑tinged critique underscores the growing unease among lawmakers about the intersection of technology, cost‑containment, and patient rights.
Doctors Detail the Burdensome Appeal Process and Systemic Ripple Effects
The roundtable also illuminated the procedural burden placed on both patients and providers. Appeals of AI‑generated denials can extend for months, during which time clinicians must allocate staff to compile additional documentation, attend hearings, and resubmit requests. Dr. Rosenblum observed that this administrative load “clogs the system because these patients are needing care for these additional problems [such as depression],” and then “other patients are getting delayed because these appointments are getting taken.” The resulting bottleneck not only prolongs suffering for those directly affected but also strains overall clinic capacity, potentially delaying care for unrelated conditions. Physicians urged CMS to reconsider the AI’s role, advocating for a model that prioritizes clinical judgment over algorithmic cost‑saving metrics.
Efforts to Curtail AI Review Stall, But Lawmakers Vow to Continue Fight
Despite the setbacks, momentum for reform persists. Advocacy groups, including the Electronic Frontier Foundation, continue to scrutinize contractor performance data, while medical societies lobby for greater transparency in AI decision‑making processes. Sen. Murray’s office has signaled plans to reintroduce a revised version of the anti‑AI‑review bill, incorporating feedback from stakeholders and emphasizing patient‑safeguard provisions. Until such legislation succeeds, Medicare beneficiaries in the pilot states remain subject to a system where financial incentives intertwine with algorithmic scrutiny, raising pressing questions about how best to balance fiscal responsibility with the imperative to deliver timely, necessary care to the nation’s seniors.
https://www.kuow.org/health/2026-10-09/the-feds-are-using-ai-to-deny-care-to-wa-seniors-sen-murray-says