Medicare WISeR prior authorizations needed Congress’ prior authorization, lawmakers say

A procedural rule could be the key to stopping new prior authorization (PA) requirements in Medicare, according to Democrats in the U.S. House of Representatives.

Rep. Greg Landsman (D-Ohio) and Rep. Suzan DelBene (D-Washington) in the House, and Sen. Maria Cantwell (D-Washington) and Sen. Patty Murray (D-Washington) in the Senate, announced they are leading a Congressional Review Act resolution targeting the Wasteful and Inappropriate Service Reduction (WISeR) model. The U.S. Centers for Medicare & Medicaid Services (CMS) launched the WISeR model in January in six states: Ohio, New Jersey, Oklahoma, Texas, Arizona and Washington.

It is the first such program in traditional Medicare to use artificial intelligence (AI) to determine prior authorizations for procedures such as skin and tissue substitute treatments, implantation of electrical nerve stimulators, knee replacements and neck vertebrae fusions.

Those medical treatments are necessary for patients, but requiring prior authorization and detaching that process from human consideration are bad ideas, said congressional Democrats who hope to stop it. They have pressed Department of Health and Human Services (HHS) Secretary Robert F. Kennedy Jr. and CMS Administrator Mehmet Oz, M.D., MBA, two key health program leaders in the administration of President Donald J. Trump.

“Instead of letting doctors decide what’s best for their patients, the Trump administration is experimenting with a dangerous AI [artificial intelligence] model that’s delaying and even denying critical care for seniors. Congress needs to act,” Landsman said in a statement with DelBene.

Rooting out wasteful spending

Oz announced the program in 2025. CMS Innovation Center Director Abe Sutton, J.D., described the importance of reducing wasteful care that provides little or no clinical benefit to patients, but that can add to health care costs while creating medical risks.

“CMS is committed to crushing fraud, waste, and abuse, and the WISeR Model will help root out waste in Original Medicare,” Oz said in a news release for last year’s announcement. “Combining the speed of technology and the experienced clinicians, this new model helps bring Medicare into the 21st century by testing a streamlined prior authorization process, while protecting Medicare beneficiaries from being given unnecessary and often costly procedures.”

Prior authorization from Congress needed

No one in Congress has supported wasteful or unnecessary health care spending. But the Democrats have noted the legislators should have a say in how the WISeR model operates.

The Congressional Review Act is a federal law that allows Congress a limited window of time to pass a resolution overturning a rule or regulatory action taken by a federal agency. The resolution, if passed, would nullify the WISeR Model.

The move came after the nonpartisan Government Accountability Office (GAO) determined this month that the WISeR Model qualifies as a rule subject to the Congressional Review Act. Procedurally, the Trump administration was required to submit the model to Congress before implementing it.

‘Largely involuntary,’ and in need of review

The GAO ruling stated the WISeR model transfers decision-making authority over certain Medicare claims to different entities that will use AI and be paid by reducing Medicare expenditures. That could affect “the rights and obligations” of physicians, other health care practitioners and beneficiaries in the six states where WISeR has started.

HHS countered that its “voluntary” models do not alter or affect those rights, and do not change Medicare eligibility, coding, coverage or payment requirements, the GAO ruling said.

However, physician participation “is largely involuntary,” wrote GAO General Counsel Edda Emmanuelli Perez. Physicians must use the WISeR model procedures for the claims for the medical treatments. Their only choice is to submit a prior authorization request, which was not required in the past, or have claims subject to prepayment medical review by a model participant, a process that previously applied only to a small number of claims, the ruling said.

Pain during the waiting process

The lawmakers’ most recent announcement focuses on procedure, but they also have begun tallying the human cost to beneficiaries.

Cantwell published a snapshot report about the effects, based on data from physicians and patients in 16 hospitals across the state. Procedures previously approved within approximately two weeks prior to WISeR, now take four to eight weeks to receive approval, according to survey data from the Washington State Hospital Association.

Her paper detailed the case of beneficiary Michael Edgerly, 78, who experienced debilitating back pain due to scoliosis and degenerative joint disease. Previously, epidural steroid injections for pain management were covered without delays. Under WISeR, a prior authorization request was denied, and he had to wait almost a month for approval for the treatment that helped him regain the ability to walk.

A physician speaks out

Cantwell’s report included direct quotations from administrators describing their concerns — all worrisome — about WISeR’s prior authorization process.

“I am concerned that some of our patients, as they are wading through the morass of WISeR, may turn to pain control alternatives that are harmful and addictive long-term,” Andrew Jones, M.D., MBA, CEO of Confluence Health in Wenatchee, Washington, said in the report. “The WISeR program is making pain management harder, which could lead to unintended and dangerous consequences.”

Kennedy agrees delays are unacceptable

In a Senate Finance Committee hearing last month, Cantwell asked Kennedy about the delays caused by PA in the WISeR program. He pledged to work with Congress on it and said a delay in patient care was unacceptable.

HHS requires 5% prior authorization across Medicare and Medicaid. However, some procedures may not be helpful or necessary for patients, but are lucrative for doctors, and HHS was “being ripped off” by Medicare fraud, Kennedy said.

AI is “supposed to allow us to detect fraud early” in health care, Kennedy said. “There’s probably kinks in the system. I will work with you to try to straighten that out.”

Kennedy conceded that the PA process also should have a human supervisor who checks the circumstances when prior authorization is denied.

What needs improvement now

If WISeR’s prior authorizations must continue, Cantwell wrote a letter to Kennedy demanding commitments to a streamlined procedure as follows:

• Require contractors administering WISeR to respond to standard claims within 72 hours and urgent claims within 24 hours.
• Require that any denial issued through WISeR include a written explanation authored by a human reviewer, not artificial intelligence.
• Prohibit contractors administering WISeR from assigning appeals to individual billing staff, rather than the responsible provider or facility.
• Improve transparency by publicly reporting the number of denials issued through WISeR and the financial gains realized by contractors administering the program.
• Prohibit contractors administering WISeR from denying care when a patient’s medical team has documented that reasonable alternatives have been considered and ruled out.
• Before expanding the WISeR program, provide Congress with a written analysis of the results of the pilot program.

Cutting through red tape

Along with Landsman from Ohio, DelBene has criticized the human cost to beneficiaries in Washington. They were joined in a statement by Rep. Frank Pallone (D-New Jersey).

“WISeR is a dangerous program that is denying care to Medicare patients so companies can profit,” DelBene said. “This program implements the same flawed prior authorization scheme from Medicare Advantage into traditional Medicare. If scaled up, it would be a back door to privatizing Medicare. It is causing needless delays, worsening conditions, and costing us more in the long run. Congress needs to step up and put an end to WISeR.”

Pallone praised the efforts to cut through “an enormous red tape barrier” now blocking access to care for potentially millions of people. “We should be making it easier for Seniors on Medicare to get the care they need, not harder,” he said.