{"schema_version":"0.10.0","id":"LR-2026-0543","record_version":1,"title":"Washington seniors face denied, delayed care under AI Medicare review program","verification":{"human_verified":false,"method":"automated_gate","auto_verified":true,"score":46.0,"score_breakdown":{"source_authority":12.1,"independent_corroboration":7.0,"implicated_party_confirmed":0.0,"citation_integrity":14.0,"specificity":3.0,"completeness":2.56,"unhedged_language":5.0},"checks":{"schema_valid":true,"every_field_cited":true,"quotes_verbatim":true,"source_fetched":true,"distinct_incident":true,"dates_plausible":true,"sources_agree":true,"source_describes_incident":true,"severe_backed_by_source":true,"record_integrity":true,"eligible":true,"about_this_case":true},"gate_version":"gate-2026-10-18.7","cross_check_model":null,"cross_check_agreement":null,"duplicate_of":null,"verified_by":null,"verified_at":"2026-11-01","extraction_run_id":null,"evidence_level":{"level":"preliminary","reason":"Publisher not yet named · subject to change","original_document":null,"reports_total":1,"reports_independent":0,"reports_derivative":0,"developing":false,"disputed":false,"rules_version":"evidence-2026-10-29.1","computed_at":"2026-11-01","history":[{"date":"2026-11-01","from_level":null,"to_level":"preliminary","reason":"Publisher not yet named · subject to change"}]},"sources_hash":"23482eb39c962b526ff27f74ce0553d714479d48efe2112645d16e75de32efe8"},"system":{"model_name":null,"model_version":null,"developer":"unknown","harness":null,"tools_granted":[],"permissions_scope":null,"autonomy_level":"unknown","guardrails_present":[],"deployment_context":"unknown","tier":null,"lifecycle_stage":null,"integration_type":null,"intended_use":"Reduce fraud and waste by requiring prior authorization for procedures deemed low-value services under the federal WISeR program","safeguard_state":null,"production_intended":null},"event":{"date_occurred":null,"date_disclosed":"2026-05-29","incident_class":"other","failure_class":null,"agent_involved":null,"secondary_failure_classes":[],"trigger":"unknown","duration":null,"detection_method":"unknown","summary":"A federal pilot program called WISeR uses AI to review prior-authorization requests for certain Medicare procedures in Washington and five other states. The vendor chosen to run the program in Washington is Virtix Health. Hospital representatives reported that patients now wait two to four times longer for authorizations, and University of Washington Medicine reported approvals rising from one to three days to 15 to 20 days. Physicians questioned whether the required medical review of AI-driven denials was taking place. Virtix acknowledged procedural problems in the first months and called them a natural part of the process. Democratic lawmakers appealed to the Government Accountability Office, which agreed on May 12, and repeal measures were then introduced in both chambers.","tags":[],"date_detected":null,"near_miss":null,"root_cause":null,"root_cause_detail":null,"failure_class_detail":null,"responsible_party":null,"adversarial_actor":null,"input_provenance":null,"time_to_contain":null,"operations_paused":null,"remediation":null,"precursor_events":null},"impact":{"direct_loss_usd":null,"remediation_hours":null,"records_exposed":null,"third_parties_affected_count":16,"severity":"major","severity_because":"Test: many third parties with a stated count of two or more affected parties. Fact: representatives from 16 Washington hospitals reported patients waiting two to four times longer.","harm_class":[],"affected_description":null,"protected_class_involved":null,"data_categories_exposed":[],"loss_range_usd":null,"reversibility":null,"downstream_exposure_count":null},"evidence":{"sources":[{"url":"https://www.kuow.org/stories/washington-seniors-face-denied-delayed-care-under-ai-medicare-review-program","publisher":"KUOW","date":"2026-05-29","type":"press","title":"Washington seniors face denied, delayed care under AI Medicare review program - KUOW","archived_url":null,"attachment":"first_report"}],"per_field_confidence":{"system.intended_use":"C","impact.third_parties_affected_count":"C","impact.severity":"D","impact.severity_because":"D","event.incident_class":"D","event.summary":"C","system.autonomy_level":"D","system.deployment_context":"D","event.trigger":"D","event.detection_method":"D","context.country":"D","system.developer":"D","event.date_disclosed":"D","context.denominator_available":"D"},"field_citations":{"system.intended_use":[{"source_index":0,"quote":"The six-year federal Wasteful and Inappropriate Service Reduction program (WISeR), which launched in Washington and five other states in January, aims to reduce fraud and waste by requiring prior authorization for procedures deemed \"low-value services.\""}],"impact.third_parties_affected_count":[{"source_index":0,"quote":"Representatives from 16 Washington hospitals reported that patients are now waiting two to four times longer to have procedures authorized, according to the Washington State Hospital Association."}],"impact.severity":[{"source_index":0,"quote":"Representatives from 16 Washington hospitals reported that patients are now waiting two to four times longer to have procedures authorized, according to the Washington State Hospital Association."}],"impact.severity_because":[{"source_index":0,"quote":"Representatives from 16 Washington hospitals reported that patients are now waiting two to four times longer to have procedures authorized, according to the Washington State Hospital Association."}],"event.incident_class":[{"source_index":0,"quote":"In the wake of that ruling, lawmakers in the House and Senate introduced Congressional Review Acts to repeal WISeR."}],"event.summary":[{"source_index":0,"quote":"The six-year federal Wasteful and Inappropriate Service Reduction program (WISeR), which launched in Washington and five other states in January, aims to reduce fraud and waste by requiring prior authorization for procedures deemed \"low-value services.\""},{"source_index":0,"quote":"Representatives from 16 Washington hospitals reported that patients are now waiting two to four times longer to have procedures authorized, according to the Washington State Hospital Association."},{"source_index":0,"quote":"Virtix Health acknowledged procedural problems in the first months of its management of thousands of Medicare claims in Washington state, but said it was a natural part of the process."},{"source_index":0,"quote":"On May 12, the GAO agreed."},{"source_index":0,"quote":"But some Washington doctors are dubious that such a professional review is taking place, according to Jeb Shepard, policy director for the state medical association."}]},"notes_on_gaps":"The sources do not name an AI model, model version or developer; the vendor Virtix Health is described as running the program, so no developer field is set. No autonomy level, agent involvement, trigger, root cause category, detection method or adversarial actor is stated, so those fields are omitted. The year of the January launch and the 'last October' report is not stated in the text, and no occurrence date is given; the article is dated 2026-05-29 in its metadata and the disclosure date is taken as that metadata date only in this note, not as a field value. No count of denied claims, records, money or remediation hours is stated. Virtix did not respond to questions about compensation, and the 10-20% figure is the American Heart Association's claim, not confirmed by the vendor. The severity tier 'major' is a judgement from the stated count of 16 hospitals reporting affected patients. No risk or control was assigned because the sources do not state which controls held, failed or were missing; the physician doubts about human review are reported as doubts. No remediation by the vendor is reported. [case created by the backfill: read by claude-haiku-5-5, backfill-2026-11-01.2, 2026-11-01; not yet reviewed] [2026-11-01: evidence level set: Preliminary (Publisher not yet named · subject to change)]"},"context":{"industry":null,"org_size_band":null,"country":"unknown","denominator_available":false,"denominator":null,"related_incident_ids":[],"systemic_exposure":null,"shared_model_id":null,"upstream_incident_id":null,"incident_evidence":null,"regulatory":null,"coverage":null},"analysis":{"sections":{"timeline":[{"text":"American Heart Association urged the government to delay WISeR implementation in a report.","quote":"In a report urging the government to delay implementation of WISeR last October, the American Heart Association said \"participating vendors will be compensated by receiving 10-20% of the savings associated with care denials.\"","source_index":0,"when":"last October"},{"text":"WISeR launched in Washington and five other states.","quote":"The six-year federal Wasteful and Inappropriate Service Reduction program (WISeR), which launched in Washington and five other states in January, aims to reduce fraud and waste by requiring prior authorization for procedures deemed \"low-value services.\"","source_index":0,"when":"January"},{"text":"Reporting describes the pilot as five months in, with new hurdles and worsening outcomes.","quote":"Five months into a pilot program that uses AI to review certain Medicare procedure requests, Washington seniors face new hurdles and worsening health outcomes, according to health care providers and lawmakers.","source_index":0,"when":null},{"text":"Virtix held a webinar with Washington state physicians.","quote":"Virtix held a webinar on Wednesday with Washington state physicians.","source_index":0,"when":"Wednesday"}]},"model":"claude-haiku-5-5","prompt_version":"backfill-2026-11-01.2","extracted_at":"2026-11-01","source_urls":["https://www.kuow.org/stories/washington-seniors-face-denied-delayed-care-under-ai-medicare-review-program"]}}