As the Centers for Medicare & Medicaid Services (CMS) prepares to roll out the Wasteful and Inappropriate Service Reduction (WISeR) Model in 2026, concerns are mounting that the initiative could bring to traditional Medicare the same kinds of care denials and administrative headaches that have long troubled private insurance and Medicare Advantage plans.
The WISeR Model, which leverages artificial intelligence (AI) and advanced analytics to automate prior authorization and pre-payment review for certain high-risk services, is being promoted by CMS as a way to root out waste, fraud, and abuse in the Medicare system.
However, critics warn that the model’s reliance on technology could replicate the most problematic aspects of private insurance, particularly the denial of medically necessary care.
The new model will be trialled initially with a pilot program from January 1 in six states – Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington.
Lawmakers have voiced alarm, urging CMS to reconsider or scrap the model altogether, citing fears that it will lead to the denial of necessary treatments for seniors and people with disabilities.
These concerns are fueled by recent experiences with Medicare Advantage and commercial insurance, where algorithm-driven prior authorization processes have resulted in high rates of wrongful denials.
Investigations have shown that private Medicare Advantage plans have inappropriately denied a significant percentage of claims that should have been covered under Medicare rules, often using opaque criteria.
Critics argue that the WISeR Model’s AI systems could similarly deny care that would otherwise be approved in traditional Medicare, with little transparency or recourse for beneficiaries.
Healthcare providers are also apprehensive about the increased administrative burden that could come with the new prior authorization requirements.
Many already find existing processes burdensome, and the introduction of automated, technology-driven reviews could exacerbate these challenges, potentially leading to delays in care and frustration among both patients and clinicians. There are also equality concerns, as automated systems may disproportionately impact beneficiaries with complex health needs, limited digital literacy, or language barriers, raising the risk of worsening health disparities.
The American Podiatric Medical Association (APMA) is one of the professional organizations to have expressed serious doubts about the plan.
“APMA will continue to communicate its concern and opposition to the expanded use of prior authorization within Medicare with CMS if it continues to move forward with the WISeR model,” the organization said.
“It’s really surprising that we are taking the most unpopular part of Medicare Advantage and applying it to traditional Medicare,” Neil Patil, a senior fellow at Georgetown and a former senior analyst at Medicare told the New York Times.
CMS has stated that all denials under the WISeR Model will ultimately be reviewed by licensed clinicians and that robust appeal rights will be maintained.
However, skepticism remains high among patient advocates and lawmakers, who are calling for greater transparency, oversight, and clear protections to ensure that the drive for efficiency does not come at the expense of patient care.
As the WISeR Model moves toward implementation, many are urging CMS to learn from the pitfalls of private insurance and to prioritize the protection of Medicare’s promise of reliable, accessible coverage for all beneficiaries.