CMS WISeR Model Launches AI-Driven Prior Authorization in Medicare

The Centers for Medicare and Medicaid Services (CMS) has approved the Wasteful and Inappropriate Service Reduction (WISeR) Model, set to launch January 1, 2026, in six states: Washington, Arizona, Ohio, Oklahoma, New Jersey, and Texas. This program integrates artificial intelligence (AI) into the prior authorization process for certain outpatient procedures under Original Medicare Parts A and B, aiming to reduce fraud, waste, and inappropriate care. The CMS intends for AI to assist in streamlining authorizations, balancing technology speed with clinical expertise for more efficient decision-making. Experts and industry observers have raised concerns about the potential impact of AI-driven prior authorizations. Key issues include longer wait times for approval, increased denials of necessary procedures, and the reliance on private contractors incentivized to deny claims. This marks a significant shift, as Original Medicare traditionally did not require prior authorizations, and the move could affect patient access to care. Medicare beneficiaries in the six pilot states will be automatically enrolled for six years, with no current opt-out option. Appeals against AI-driven decisions are permitted but must involve the patient’s primary care physician, though the exact appeal processes remain unclear. Industry experts emphasize the importance of human oversight in appeals to mitigate risks associated with AI decision-making. CMS leadership underscores that the initiative aims to prevent unnecessary and costly procedures by ensuring appropriate use of medical services. The program also envisions AI as a tool to support clinical decisions, such as scheduling and diagnostics, enhancing efficiency rather than replacing medical judgment. As the pilot progresses, stakeholders await clarity on the metrics CMS will use to evaluate success and whether the WISeR Model will be expanded or revised after its initial six-year period. The program signals a notable shift in Medicare’s approach to managing service utilization, demonstrating an increased adoption of AI technology within federal healthcare regulatory frameworks.