WISeR under fire in Congress amid reports of delays in Washington state

Senate Democrats are calling for a stop to the Wasteful and Inappropriate Service Reduction pilot of prior authorization powered by artificial intelligence in traditional Medicare, arguing that WISeR is suffering from the shortcoming they’ve been predicting for months. 

A resolution introduced May 20 seeks to overturn the pilot, currently operating in six states, using Congress’ authority to oversee rules from federal agencies. As Healthcare Dive explained, the Government Accountability Office indicated WISeR is subject to the Congressional Review Act because it represents agency rulemaking and therefore should have been submitted to Congress.  

The resolution follows an April report from Sen. Maria Cantwell (D-Wash.), who represents one of the six states in the WISeR pilot, which found that authorizations that used to be provided within three days were now taking up to 20. That has left patients waiting for decisions and providers devoting more resources to managing claims – and, for the first time in traditional Medicare, denials – according to the report. 

Congress has until mid-July to try to force a vote that would repeal WISeR. On June 9, the House Appropriations Committee took a step forward, voting unanimously to block funding for WISeR in 2027. It’s the latest chapter of a story that’s been unfolding quickly with no shortage of drama. 

Closing a gap in prior authorization

WISeR emerged from the CMS Innovation Center last summer to augment prior authorization using AI-enabled tools to review what CMS has deemed low-value services. The program brings prior authorization to traditional Medicare and aims to avoid inappropriate utilization for 17 specific procedures that show patterns of overuse, namely nerve simulator implantations and certain spinal procedures. 

In theory, WISeR represents a missing link in the effort to reform prior authorization. Earlier last summer, CMS had announced a pledge from Medicare Advantage, Medicaid managed care, and commercial insurers to reduce the administrative burden of prior authorization through standardization, transparency, and real-time communication. That pledge appears to be working, as AHIP data published in April pointed to an 11% reduction in prior authorizations among major commercial insurers. 

Government-sponsored Medicare wasn’t part of the pledge. WISeR offered an opportunity to test automated prior authorization and wade out fraud, waste, and abuse in Medicare spending, CMS said in its release announcing WISeR.   

The model is set to run until the end of 2031 in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. A successful pilot would theoretically provide justification to apply prior authorization to more services and include more states. 

However, WISeR has faced significant opposition. Democratic representatives warned in August that the program would limit access to care and introduced legislation in November to block the model from being put into place. The warning fell on deaf ears, and the bill never came to vote. 

Not the first time concerns have been raised

AI’s role in prior authorization is a familiar topic on Capitol Hill. A 2024 report found Medicare Advantage plans had increased prior authorization denials after incorporating AI into the care approval process.  

One contention among WISeR critics was that the same technology vendors powering Medicare Advantage plans’ automated prior authorization programs would be used in traditional Medicare. To that end, Sen. Cantwell’s report said the model of compensating companies for denying claims puts “profits over care” and “weaponize[s] AI-driven medical determinations…for the opportunity to maximize profitability.” 

The 15- to 20-day wait times for approvals, according to data from the Washington State Hospital Association, exceed CMS’ own standards of one day for urgent care and three days for standard care. Meanwhile, the wait time for medical procedures covered in the program is now up to four times as long. As the report put it, “patients are subject to delays or denials which did not exist prior to the WISeR Model.” 

Both the House of Representatives and Senate are expected to be in session prior to the deadline for forcing a vote to repeal WISeR. Even if Congress doesn’t act, it’s safe to say the scrutiny will continue.   

Brian Eastwood is a Boston-based writer with more than 10 years of experience covering healthcare IT and healthcare delivery. He also writes about enterprise IT, consumer technology, and corporate leadership.