THE BILL
On May 12, the Congressional Research Service released its first formal overview of a Medicare experiment that has been quietly underway since New Year’s Day. It is called the Wasteful and Inappropriate Service Reduction Model, or WISeR for short, and it represents the largest expansion of prior authorization into traditional Medicare in the program’s history.
For decades, prior authorization has been the defining frustration of private insurance. Your doctor says you need a treatment. Your insurance company says wait. Traditional Medicare has largely been spared this. In 2023, there were 1.8 prior authorization determinations per Medicare Advantage beneficiary, compared with 0.01 per beneficiary in traditional Medicare. That is not a typo. Traditional Medicare has been, in practical terms, a prior authorization free zone. Congress.gov
Until now.
WISeR is a six year pilot running through 2031 in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. It targets a specific set of services: skin substitutes used to treat severe wounds, orthopedic pain management procedures, electrical nerve stimulator implants, incontinence control devices, and services related to the diagnosis and treatment of impotence. KFF
The reviewers are not CMS staff. They are private technology companies using AI to decide whether the care your doctor ordered is appropriate. And here is the part worth lingering on. Participants’ payments will be a percentage of the observed cost savings, based on requests that were reviewed but did not lead to a paid claim. Moss Adams
Read that sentence again. The companies reviewing the requests get paid more when they generate more denials.
THE THREE LENSES
For patients. If you live in one of the six pilot states and you are on traditional Medicare, the chief promise of that coverage just narrowed. Roughly 1.1 million traditional Medicare beneficiaries nationwide received at least one WISeR targeted service in 2024, with 86 percent accessing some form of orthopedic pain management. That is not a niche population. It is older Americans living with chronic back pain, joint pain, and non healing wounds. Appeals are allowed. But every step is time. Time when someone is in pain. Time when a wound is not healing. McKnights Home Care
The track record is not encouraging. An Office of Inspector General report found that 75 percent of denied prior authorization requests in Medicare Advantage were overturned upon appeal, and a 2022 OIG report revealed that MA plans routinely use prior authorizations to deny access to services even when those services meet Medicare coverage guidelines. The system being imported into traditional Medicare has, in its private sector form, been wrong three times out of four when patients pushed back. McKnights Home Care
For insurers. Here is where it gets strange. In July 2025, the Trump administration announced a voluntary effort in which dozens of private health insurers pledged to impose fewer prior authorization requirements and streamline the review process, and later that same week the administration announced the WISeR model to expand these types of requirements in traditional Medicare. The same week. One hand reducing prior auth in the commercial market while the other hand introduced it to the federal program that had been free of it. KFF
For health systems. New workflows for submissions, tracking numbers, pre payment holds, and appeals. Cash flow risk rises. So does administrative cost. Associated services tied to a non affirmed primary procedure are at risk of denial too, meaning one rejection can cascade. For rural and independent providers operating on thin margins, this is not a paperwork problem. It is a sustainability problem.
MY TAKE
There is a real problem WISeR is trying to solve. Spending on skin substitutes alone in 2024 was over 20 times higher than in 2019, driven by a steep rise in price per service. That is not normal growth. That is a billing pattern that demands scrutiny.
But the design does not match the problem.
If the issue is fraud in a narrow set of services, the answer is targeted coverage policy. Tighter coding rules. Direct enforcement. And CMS has already done much of that work. Nationwide changes to payment policy beginning January 1, 2026, are expected to achieve a 90 percent reduction in spending for the one service, skin substitutes, that accounts for the majority of WISeR service spending. That policy change, by itself, addresses the largest single driver of waste WISeR was built to combat. It did not require AI. It did not require contractors with denial linked compensation. It required CMS to do its job. KFF
What WISeR adds on top is a structure that has not served patients well anywhere it has been tried. A 75 percent appeal overturn rate in Medicare Advantage is not evidence of accurate determinations. It is evidence of a system that says no first and asks questions later, because saying no costs the reviewer nothing and the patient everything. Bolting AI onto that model does not fix the incentive. It accelerates it.
There is a version of prior authorization where reviewers are paid the same whether they approve or deny. There is another version where reviewers earn a cut of what gets withheld. Those are different systems with different outcomes. CMS picked the second one.
The pilot is small. The first year impact will be modest. But pilots are how programs get normalized. And once prior authorization is in traditional Medicare’s bloodstream, it does not contract. It expands.
Worth watching. And if you live in one of those six states, worth asking your representative what they think about it.