WISeR spending or unneeded delays in health care? Prior authorizations, AI in Medicare prompt concerns

A new Medicare model of value-based payment aims to crack down on waste in health care across six states.

But advocates say it will add to the burdens of prior authorizations — already a huge problem across the nation’s health care system.

Three weeks into 2026, Medicare’s new WISeR model has started, and so has debate about the intended and unintended effects of the payment model announced by the U.S. Centers for Medicare & Medicaid Services (CMS).

The WISeR (Wasteful and Inappropriate Service Reduction) model will use artificial intelligence (AI) technology to review physicians’ recommended treatments for a number of medical conditions for beneficiaries enrolled in traditional Medicare in six states.

Critics agree that no one wants wasteful spending, but the WISeR model has a major problem.

“Essentially, this administration decided to use big tech and give them a contract to deny claims to seniors, and they're choosing to go after what they think will be noncontroversial claims because they want to start the process of people being OK with AI denying claims,” said Rep. Greg Landsman (D-Ohio), a co-sponsor of legislation that would end the WISeR model.

“We believe you've got to stop it immediately,” Landsman told Medical Economics. “I mean, it's one thing to have human beings denying claims, and it's already a problem in terms of people getting the health care they need. And remember, physicians are the ones asking for this health care for their patients. And you know now it's going to be a computer system, and it's not one that's learning, it's just denying claims faster so that they can save money at the expense of American seniors.”

How it started

CMS Administrator Mehmet Oz, M.D., MBA, announced the new model in June 2025.

“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 at the time. “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.”

Root out waste

Oz and CMS Innovation Center Director Abe Sutton, J.D., touted the importance of reducing wasteful care. Those services provide little or no clinical benefit, but add to the financial costs of care and create greater risks to patients.

“Waste in health care represents up to 25% of health care spending in the United States,” the official announcement said. The CMS leaders cited the Medicare Payment Advisory Commission, whose analysis of 2022 spending estimated Medicare spent $5.8 billion on services with minimal benefit.

WISeR would cover electrical nerve stimulator implants and knee replacements. It would not apply to inpatient-only services, emergencies or when a delay would cause substantial risk to patients. The WISeR model started this year in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington.

Fewer and faster prior auths, or more?

In 2025, health care organizations and their advocates cheered when Oz, HHS Secretary Robert F. Kennedy Jr. and President Donald Trump said insurance companies were on notice to streamline prior authorizations, or the federal government would do it for them.

But the WISeR model set off alarm bells signaling more prior auths, not fewer. The issue is important enough that prior authorization could be front and center in health policy debate in 2026, said Anders Gilberg, MGA, senior vice president, government affairs for the Medical Group Management Association.

“So the irony is, Administrator Oz, on one hand, has been kind of jawboning insurance companies about reducing the burden of prior authorization on physicians,” Gilberg said in a Medical Economics interview. “But at the same time, they’re implementing a plan to expand prior authorization in traditional Medicare, which doesn’t really have (prior authorization). That’s the best part of traditional Medicare.”

Skin substitutes: Bad medicine influences policy

The WISeR Model takes aim at another target: skin substitutes used in wound care.

In the past few years, skin substitute spending ballooned under original Medicare and could hit $15 billion for 2025. The situation prompted investigations, court cases and stern warnings from the Health and Human Services Office of Inspector General (HHS-OIG). After egregious cases of fraud came to light, Medicare changed its payment policy for skin substitutes. Previously, skin substitutes did not need prior authorization under traditional Medicare, and experts acknowledged that the prior authorizations used in Medicare Advantage (MA) likely blocked skin substitute billing in MA.

Good prior authorizations?

Mara McDermott, J.D., CEO of the advocacy organization Accountable for Health, said she had “been thinking about this a ton,” regarding the WISeR model.

Accountable care organization leaders “kind of did a deep sigh” when they heard about new prior authorizations in Medicare, McDermott said. Yet, skin substitutes became an example of prior authorizations creating a benefit in health care.

“Prior auth can be great if it stops a patient from being…infected or having an amputation they don't need because they're having inappropriate wound care,” McDermott told Medical Economics. “And to me, it has seemed like the real rubber-meets-the-road moment is to figure out, how do you get more of the good stuff and less of the bad stuff, right? And, yes, speeding it up. But I think that skin substitutes are a really strong indicator that sometimes more controls are needed.”

Lawmakers take notice

The WISeR model and prior authorizations have received attention from Congress.

Landsman and Rep. Bonnie Watson Coleman (D-NJ) have introduced the Ban AI Denials in Medicare Act, legislation that would stop the WISeR model. They aren’t alone — 72 lawmakers recently signed a letter to House and Senate leadership asking for congressional consideration of the model.

The legislators said they do support innovation and want to eliminate waste. But evidence from Medicare Advantage already shows the plan administrators “routinely use prior authorizations to deny access to services, even when those services meet Medicare coverage guidelines,” the legislators wrote.

“These denials delay patient access to care while creating unnecessary administrative burdens for providers — taking them away from caring for patients,” wrote the group, which included congressional physicians Rep. Ami Bera, M.D. (D-CA), Rep. Kim Schrier, M.D. (D-WA), and Rep. Maxine Dexter, M.D. (D-OR). “We are concerned that expanding the prior authorization process to traditional Medicare could have similar results.”

Health care needed? Just wait and see

In some cases, the delays may be needless. The lawmakers cited a 2022 HHS-OIG report that found that in Medicare Advantage, 75% of denied prior authorization requests were overturned on appeal, “suggesting initial denials were often unfounded.”

It’s similar to what Landsman hears from constituents, and the complaints could point to a better use for AI in health care.

“The number one thing I hear is, it took forever, you know, I submitted this, and then it got denied. It was absurd that it got denied, so we fought it, and we ultimately got it reversed,” Landsman said. “That's the No. 1 thing I hear from physicians and from their patients, and that means that they should be using AI to reduce the number of wrongfully denied claims. That’s the big issue, is that for the most part, people get denied their claims, and then it gets reversed because it was a bad decision, that it was health care that the patient desperately needed. So that's where I would use AI.”

The Ban AI Denials in Medicare Act has had one committee hearing this year. Landsman said he hopes for bipartisan support and a vote on it.