Subject: Pre-approval in Medicare
https://www.nytimes.com/2025/0...
Medicare Will Require Prior Approval for Certain Procedures

A pilot program in six states will use a tactic employed by private insurers that has been heavily criticized for delaying and denying medical care.

By Reed Abelson and Teddy Rosenbluth, The New York Times, Aug. 28, 2025

Like millions of older adults, Frances L. Ayres faced a choice when picking health insurance: Pay more for traditional Medicare, or opt for a plan offered by a private insurer and risk drawn-out fights over coverage.

Private insurers often require a cumbersome review process that frequently results in the denial or delay of essential treatments that are readily covered by traditional Medicare. This practice, known as prior authorization, has drawn public scrutiny…

The Centers for Medicare and Medicaid Services plans to begin a pilot program that would involve a similar review process for traditional Medicare, the federal insurance program for people 65 and older as well as for many younger people with disabilities. The pilot would start in six states next year…People enrolled in traditional Medicare who live in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington State will be included in the experiment, which is expected to start in January and last for six years….

The federal government plans to hire private companies to use artificial intelligence to determine whether patients would be covered for some procedures, like certain spine surgeries or steroid injections. Similar algorithms used by insurers have been the subject of several high-profile lawsuits, which have asserted that the technology allowed the companies to swiftly deny large batches of claims and cut patients off from care in rehabilitation facilities.

The A.I. companies selected to oversee the program would have a strong financial incentive to deny claims. Medicare plans to pay them a share of the savings generated from rejections…. [end quote]

This is a flashing red light.

It’s clear that the pilot program will be declared a “success” and applied to the rest of the country. It’s equally obvious that giving for-profit companies a “veto” over care will transform Medicare into Medicare Advantage – but patients will pay more for Medicare and get fewer benefits. Obviously the few procedures that will require pre-approval will expand into many expensive procedures.

Using AI will couple the inaccuracies of AI with the financial incentives to deny treatment.

This is a problem of Macro significance because it affects millions of Medicare beneficiaries.

Wendy