WISeR Update:Report Finds Delayed Care and Increased Administrative Burden
U.S. Senator Maria Cantwell (D-WA) released findings yesterday on the WISeR (Wasteful and Inappropriate Services Reduction) Model, launched by the Center for Medicare and Medicaid Innovation (CMMI) on January 1, 2026. This six-year model is testing the use of artificial intelligence (AI)-powered prior authorization (PA) for 13 services in Traditional Medicare across six states. You may recall that Senator Cantwell is among several Democrats who have been urging CMS to cancel the model since its announcement.
Report Findings
The brief report, prepared by the senator’s staff, includes data from the Washington Hospital Association. The report found that:
Patients are waiting 2 to 4 times longer to complete procedures covered by the WISeR Model due to authorization delays.
The University of Washington Medical System has 100 patients currently awaiting approval for their epidural steroid pain injections.
The model has forced the adoption of costly new billing practices.
Denials are often inconsistent with clinical criteria and lack a clear rationale.
The report also raises concerns about the model's financial incentives, in which third-party administrators receive a bonus for each claim they deny. The report states, “This model incentivizes WISeR contractors to weaponize AI-driven medical determinations not for the sake of efficiency, as it could be used, but for the opportunity to maximize profitability.”
Senate Finance Committee Hearing
During a Senate Finance Committee hearing this past Wednesday, Senator Cantwell raised her concerns and shared the report with Health and Human Services Secretary Robert F. Kennedy, Jr. The Secretary acknowledged the delay was inappropriate and said he would work with Senator Cantwell to resolve the issues. You can view the exchange between Senator Cantwell and Secretary Kennedy HERE.
However, it is important to remember that the Centers for Medicare & Medicaid Services (CMS) has been very bullish on this model and views it as a way to address waste and improve efficiency in the Medicare program. CMS has indicated that insights from this model could be applied to other states or medical services and that the model could be expanded in the future. I believe CMS will continue to defend and promote this model, which it views as clearly aligned with its stated goals and priorities.
Brief History of the WISeR Model
This model has sparked controversy since its announcement last summer. Concerns have been raised about its use of PA in Traditional Medicare (PA has largely been used in the Medicare Advantage environment); its use of AI to conduct PA reviews; and its incentive structure, which has been described as rewarding contractors for denying care. Some highlights from the model's brief history.
June 27, 2025: CMS announces the WISeR Model with a January 1, 2026, launch date and plans to launch gold carding by mid-2026.
August 7, 2025: House Democrats submit a letter to CMS raising concerns about the model and requesting that the agency respond to their questions.
September 18, 2025: Senate Democrats submit a letter to CMS urging CMS to halt implementation and allow a formal comment and rulemaking process.
October 23, 2025: The American Hospital Association submits a letter to CMS expressing concerns about the model and requesting a six-month delay in its implementation.
November 11, 2025: House Democrats introduce the “SMARTER (Streamlined Medical Approvals for Timely, Efficient Recovery) Care Act,” a bill aimed at blocking WISeR.
December 16, 2025: A group of Democratic lawmakers introduces the SMARTER bill in the Senate.
January 1, 2026: CMMI launches the WISeR Model.
January 29, 2026: Modern Healthcare publishes an article stating, “Less than a month into the program that introduced prior authorizations to fee-for-service Medicare, providers say they are running into the kinds of problems they warned about last year.”
February 2026: The American Medical Association launches an effort to collect feedback from clinicians directly affected by WISeR.
February 10, 2026: KFF News releases an analysis of the potential impact of WISeR.
March 25, 2026: The Electronic Frontier Foundation (EFF) files a lawsuit against CMS to obtain transparency into the WISeR model. The suit was filed in California.
March 27, 2026: In response to recent reports about WISeR and a lawsuit filed by a digital and privacy rights organization, 35 House Democrats send a letter to the House Appropriations HHS subcommittee, requesting that the next appropriations bill include language to exclude funding for WISeR or any similar model.
April 3, 2026: CMS announces a delay in implementing two services under the Wasteful and Inappropriate Services Reduction (WISeR) model: Deep Brain Stimulation for Essential Tremor and Parkinson’s Disease (NCD 160.24) and Percutaneous Image-Guided Lumbar Decompression for Spinal Stenosis (NCD 150.13) (HCPCS 02756T, G0276).
Please let me know if you have any questions or wish to discuss.
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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