Medicare Faces Lawsuit Over WISeR (AI Prior Auth Pilot)
I know many of you are closely watching the implementation of the Wasteful and Inappropriate Service Reduction (WISeR) Model. I want to inform you that the Electronic Frontier Foundation (EFF) is suing CMS to gain transparency into the WISeR model. The suit was filed in California.
WISeR was launched on January 1, 2026, in six states. Under the model, CMS uses artificial intelligence (AI) to review prior authorization requests for a specific set of services for traditional Medicare (previously called fee-for-service Medicare). Model participants are the technology vendors CMS has contracted to handle the prior authorization requests.
Key Takeaways
EEF is a digital and privacy rights nonprofit.
EFF submitted a Freedom of Information Act request to CMS seeking records related to WISeR, but the agency has not yet responded.
The request was related to the technology companies participating in the pilot and any evaluations on accuracy, bias, or hallucinations in their technology.
With their lawsuit, EEF has raised a number of concerns:
There is little information about how the AI algorithms used in WISeR work.
It is unknown what training data they rely on.
It remains unclear whether WISeR has any safeguards against systemic flaws such as algorithmic bias, privacy violations, and wrongful denials of care.
EEF’s position is that the model has already delayed care for seniors and increased administrative burden on providers since its launch in January.
A Washington Post article cited in the lawsuit found that in Texas, only 62% of requests under the pilot were initially approved, rising to 84% after they were reviewed by a human. In comparison, 92% of prior authorization requests were fully or partially approved nationwide in MA.
While some members of both chambers of Congress have expressed opposition to WISer, the agency's political leadership has consistently stated that technologies such as AI are the solution to many Medicare issues. Regarding prior authorization specifically, they have publicly declared that it simply needs to be “fixed” and that it is an essential tool that can act as a barrier to low-value care. I expect the agency will strongly defend this model.
I will keep you posted as I learn more.
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For more information and questions, please contact:
Sheila Madhani
Madhani Healthcare Consulting
Email: smadhani@madhani-health.com
Tel: (202) 679-2977