Bill Curry, 65, raises cattle on the same land in rural Oklahoma that was once owned by his father and previous generations. Every quarter for several years, he has traveled two and a half hours to Oklahoma City to receive a spinal epidural to treat his back pain.
But this year, because of a new Medicare program, Curry has traveled a little more often.
In February, while on a trip, she was unexpectedly told she needed prior approval for the procedure. Then, about a month later, he received the shot again, for a total of 10 hours of travel. His clinic wanted him to come a third time, something he had never been asked to do 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 prior approvals in traditional Medicare, the federal health insurance program for people 65 and older or with disabilities. Medicare had previously prevented the practice, also known as prior authorization, that 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 are prone to fraud or misuse. Powered by artificial intelligence, the program, called the Wasteful and Inappropriate Services Reduction Model, or WISeR, aims to save the federal government money and protect patients from potentially unsafe or unnecessary care.
However, early reviews from Oklahoma and other pilot states (Arizona, New Jersey, Ohio, Texas, and Washington) suggest that implementation of WISeR has not been easy. Patients, doctors and other health professionals who spoke with KFF Health News say the effort has created confusion, errors, long wait times and stress. Some described the rollout as “horrible” and say people enrolled in Medicare in the pilot states are now getting caught up in the same bureaucracy as those with private insurance.
A key concern is that everything happened too hastily. WISeR was announced in June 2025 and launched in mid-January.
That was “faster than normal” for the federal government, said Todd Baker, who recently resigned as executive director of the Ohio State Medical Association. Doctors “just had to figure it out,” added Jeb Shepard, policy director for the Washington State Medical Association.
Government contractors have also acknowledged the rapid pace. “We've had an aggressive rollout from the time we were notified to the time it went live,” said Jeremy Friese, CEO of Humata Health, the Oklahoma provider. Technology executives serving 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 administers the program, did not comment on the implementation timeline. But he said in a statement that the goal of these reforms is to ensure that prior authorization is efficient, fast and agile.
“The model aims to reduce inappropriate care without delaying appropriate care,” he said.
Mehmet Oz, leader of the Centers for Medicare and Medicaid Services, told NewsNation in December that they were “implementing some prior authorization on abusive practices.”
“The purpose of this is not to deny attention,” Oz continued. “It's to make sure you get the care you need and deserve, not the care some unscrupulous doctor wants to give you.”
Medicare has struggled in recent years with suspicions of fraud associated with particular services. The Department of Health and Human Services' inspector general warned in September that program spending on skin substitutes, for example, had increased nearly 700% in two years, raising “significant concerns about fraud, waste and abuse.” Skin substitutes are among 13 therapies currently subject to review by WISeR.
The program also imposes prior authorization requirements for kyphoplasty, a surgery for spinal fractures, which a report by the Medicare Payment Advisory Commission noted as overused.
Sutton acknowledged, however, that “the percentage of providers committing waste, fraud and abuse is small.”
Consumers and doctors largely hate prior authorization. Even as federal health officials test the process for Medicare, the Trump administration is trying to reduce it for those with private insurance. According to a KFF survey conducted in January, 69% of insured adults consider prior authorization to be a burden on care.
Through WISeR, doctors and their staff log into online portals to submit medical records to justify procedures. Using artificial intelligence, the systems quickly approve applications that meet the program's criteria, Humata CEO Friese told KFF Health News. He said there is an “immediate yes” in 88% of cases where clinical data supports an approval.
CMS has touted the process as one in which decisions are issued within 72 hours. After that, doctors receive a “universal tracking number,” which allows them to schedule the procedure and receive payment. However, in practice, participants say the process is not easy at all.
The University of Washington 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 relied on data from hospital associations. “Patients are now subject to delays or denials that did not exist before the WISeR model,” the report says.
Curry, the Oklahoma rancher, said he could go to Kansas for future treatments and avoid the approval process. Dorota Gribbin, a New Jersey-based physical medicine and rehabilitation physician, said that when the clearance came for one of her patients who needed a procedure for back pain, the patient had gone to the hospital for more expensive care.
Jennifer Valle, precertification and insurance supervisor at Clinical Radiology of Oklahoma, said that when it comes to kyphoplasties, there has been a lot of criticism from reviewers. Other times, the information his practice provides to CMS is overlooked, he said, and reviewers request images that are already on file.
Smooth claims are supposed to be paid within 15 days, said James Webb, a musculoskeletal radiologist in Tulsa, Oklahoma, who has also been frustrated by the pre-approval and reimbursement process for kyphoplasties. “What we've been seeing is delays of six to eight weeks,” he said.
“It's been horrible,” said Jerry Sobel, a Phoenix-area pain doctor. “From the beginning it seemed like there was no organization.” Sobel said that as of May, Medicare had not paid for nine epidurals.
“We continually monitor operations and work closely with stakeholders to address questions and improve the provider experience,” said Sundar Subramanian, CEO of Zyter, which has the contract for Arizona.
During a webinar in April, another Zyter executive acknowledged a long delay in payments that stretched into January. Those delays “are currently being resolved,” Medicare's Sutton said, without providing further details.
When asked about other issues, including what doctors suspect are errors caused by AI, Medicare's Sutton said the agency appreciates “feedback on providers' experience.” It will be used “to help providers better understand WISeR processes,” he said.
Although CMS providers say humans make the final decisions about approvals, doctors and their staff believe that artificial intelligence is playing a major role in the process and that denials are sometimes the result of AI hallucinations that distort or fabricate information.
One Arizona doctor, who was not authorized by his practice to speak, recalled a denial that said his patient was not eligible for procedures in the thoracic region or mid-back. The patient needed an injection in the neck. Webb, the Oklahoma radiologist, documented four times that a patient lacked numbness, and yet his WISeR request was denied, citing numbness that, in the reviewer's interpretation, would rule out the spine surgery procedure.
Friese, Humata's CEO, said he hasn't heard of any AI hallucinations.
The process is also raising government costs. With more denials, more appeals are filed with Medicare administrative contractors. The government pays contractors to handle appeals, and Medicare's Sutton acknowledged that the agency “has taken into account potential changes in the volume of Medicare appeals due to the WISeR program and its associated costs.”
Eighty-four percent of commercial insurers already use artificial intelligence tools, according to a survey published in 2025 by the National Association of Insurance Commissioners, although they have consistently said that artificial intelligence is not used to deny prior authorization requests.
Its use in Medicare risks introducing friction and frustration into the program and racking up costs for its beneficiaries. Prior authorization saves insurers money, in part because it makes patients pay a price in wait times and inconvenience, said Miranda Yaver, a health policy researcher at the University of Pittsburgh who studies the technique.
“People are going to end up getting caught up in a lot of red tape, they're going to have to be on hold and they're going to be diverted,” he said. It is often asked whether prior authorization simply shifts costs to patients and doctors, rather than saving them.
Some doctors involved in the Medicare prior authorization experiment believe it will inevitably expand beyond a few services that Washington officials consider prone to fraud.
“Everyone knows that if this pilot project works, it will be prior authorization for basically all procedures,” said Mary Clarke, a family physician in Stillwater, Oklahoma. “If they can show that they can save money, then that will be extrapolated and applied to other procedures and many other things in other states.”
When asked if CMS is considering expanding its prior authorization pilot program, Sutton said in her statement that “no changes are currently being considered” to the list of services subject to the WISeR program, “but CMS continues to evaluate whether any changes are warranted.”
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KFF Health News Southern Correspondent Lauren Sausser contributed to this report.
