CLINICAL AI

The Centers for Medicare & Medicaid Services faces mounting Congressional opposition to its Wasteful and Inappropriate Service Reduction (WISeR) Model, a controversial pilot program that would fundamentally alter how Traditional Medicare operates by introducing artificial intelligence-powered prior authorization requirements. Led by Senate Finance Committee Ranking Member Ron Wyden, Senate Special Committee on Aging Ranking Member Kirsten Gillibrand, and Senate Permanent Subcommittee on Investigations Ranking Member Richard Blumenthal, eighteen Senate Democrats have called for an immediate halt to the program, arguing it represents a dangerous erosion of Traditional Medicare's foundational principles.
The WISeR Model, scheduled to launch January 1, 2026, will require healthcare providers in six states—New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington—to obtain prior authorization from third-party vendors using AI technology before delivering seventeen specific services to Traditional Medicare beneficiaries. These services include electrical nerve stimulators, cervical fusion procedures, epidural steroid injections, and skin substitute treatments, among others. While CMS characterizes the program as voluntary for participating vendors, it is functionally mandatory for healthcare providers and patients, as claims submitted without prior authorization will face mandatory pre-payment medical reviews, creating significant administrative burdens and potential care delays.
The Congressional opposition stems largely from documented problems with AI-powered prior authorization in Medicare Advantage plans, where similar technologies have led to dramatic increases in coverage denials. A recent Senate Permanent Subcommittee on Investigations report found that major insurers like UnitedHealthcare, Humana, and CVS used AI tools to systematically deny post-acute care at rates significantly higher than other types of care, with denial rates continuing to rise year-over-year from 2019 to 2022. Perhaps most concerning, internal documents revealed that these denial patterns were driven by profit motives rather than patient outcomes, with companies setting targets to keep patient stays within narrow algorithmic predictions regardless of clinical necessity.
Financial incentive structures within the WISeR Model have raised additional red flags among critics. Model participants will receive compensation based on "a share of averted expenditures," creating direct financial rewards for denying services. This contingency fee approach mirrors problematic arrangements that have led to adverse outcomes in Medicare audits and are prohibited by several states when commercial plans make payment determinations. Healthcare advocates warn this creates "AI bounty hunters" who profit by restricting medically necessary services, fundamentally aligning financial incentives against patient care.
Transparency and oversight concerns further complicate the WISeR Model's implementation. Democratic lawmakers have emphasized that the lack of technical transparency about how AI algorithms make coverage decisions makes it nearly impossible for CMS to ensure adequate program oversight. With documented AI error rates as high as 90% in existing Medicare Advantage applications—where appeals reverse the vast majority of initial denials—the introduction of similar technologies into Traditional Medicare raises serious questions about due process and patient protection. The American Medical Association reports that 61% of physicians are already concerned that health plans' use of unregulated AI is increasing prior authorization denials, with some AI tools producing denial rates 16 times higher than typical human review processes.
The WISeR controversy represents a critical inflection point for American healthcare policy, as it threatens to fundamentally alter Traditional Medicare's character by importing the most criticized aspects of managed care into the fee-for-service system. The program's launch would mark the first systematic introduction of AI-powered coverage restrictions into Traditional Medicare, potentially setting a precedent for broader algorithmic oversight of physician decision-making. As healthcare stakeholders await CMS's response to Congressional concerns, the debate over WISeR illuminates deeper questions about the appropriate role of artificial intelligence in healthcare coverage decisions and whether technological efficiency should take precedence over clinical judgment and patient access to care.