Summary
Six-year CMS Innovation Center model that uses technology-enabled prior authorization, including artificial intelligence and machine learning with human clinical review, to target select Medicare fee-for-service items and services considered vulnerable to fraud, waste, and abuse in six pilot states.
Healthcare Implications
The model introduces AI-assisted prior authorization for Original Medicare beneficiaries, affecting providers and patients through new review workflows, documentation expectations, and oversight of denials, and raising important questions about transparency, fairness, and access to medically necessary care when AI is used to flag or deny services.