The WISeR program, launched in January in six states—New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington—utilizes AI and machine learning to manage Medicare prior authorizations. It is scheduled to operate until the end of 2031. The program covers approximately a dozen medical services, including nerve stimulation, epidural steroid injections, and cervical fusions.
Documents obtained by the Electronic Frontier Foundation indicate that contractors are financially incentivized to deny care. CMS pays vendors 25 percent of the regional benchmark cost for every denied request. While an 'Aggregate Quality Score' exists to penalize inappropriate denials, the financial impact is limited, with companies retaining 90 percent of their potential earnings even with failing quality scores.
Implementation issues have been widespread. Vendor Virtix denied 3,233 out of 6,096 requests in one reporting period. While the program mandates a 72-hour decision window, many requests remain pending for weeks or months. One case documented by the EFF involved a request that remained unresolved for 83 days, leading to significant delays in patient care.
The administration plans to expand the program to include oncology, air ambulance transport, advanced imaging, cardiac catheterization, pacemakers, ICDs, and genetic testing. Lawmakers, including Senator Patty Murray, have expressed opposition to the expansion, citing the negative impact on patient care and the lack of transparency regarding the program's operational design.
