A CMS pilot program that would add prior authorization for some traditional fee-for-service Medicare services has come under increased scrutiny by some members of Congress, including a call to pause the program.
The WISeR initiative
The Wasteful and Inappropriate Service Reduction (WISeR) initiative, unveiled in June, will launch Jan. 1 in Arizona, Ohio, Oklahoma, Texas, Washington and New Jersey. CMS plans to partner with AI and machine learning firms to test ways to expedite prior authorization while reducing unnecessary or noncovered services. Contractors will be paid based on how much they save the federal government by halting payments for inappropriate care.
CMS Administrator Mehmet Oz, MD, said the model will “help root out waste in original Medicare.”
Lawmaker concerns
At a Sept. 4 House Energy and Commerce Committee hearing, Ohio Rep. Greg Landsman said the program has been referred to as an “AI death panel.” He is calling for the pilot to be halted until an independent review board is established.
“You get more money if you’re that AI tech company if you deny more claims,” Mr. Landsman said. “That is going to lead to people getting hurt.”
At the same hearing, New Jersey Rep. Frank Pallone expressed concern that the AI model will “result in denials of lifesaving care and incentivize companies to restrict care.”
Mr. Landsman and Mr. Pallone represent states that will pilot the program, but concerns go beyond the states involved. Illinois Rep. Jan Schakowsky and Wisconsin Rep. Mark Pocan introduced a resolution Sept. 11 opposing the WISeR initiative.
“Every year, millions of seniors on Medicare Advantage are unfairly denied the care they need because of burdensome prior authorization rules,” Ms. Schakowsky said. “Now, the Trump administration plans to implement these same requirements on certain traditional Medicare services — threatening access to care for millions more. This is unacceptable.”
The House Appropriations Committee on Sept. 9 advanced a 2026 spending bill that included an amendment blocking funding for the program. Florida Rep. Lois Frankel, who introduced the amendment, said the program “would create “new roadblocks for seniors who depend on Medicare coverage.”
“Let’s not bring this nightmare to Medicare, the one program that seniors still count on for guaranteed straightforward care,” she said.
The bill is awaiting a vote by the full House.
One executive’s perspective
Phoenix-based Banner Health is one of the health systems that will be affected by the pilot program. Senior Vice President of Finance Adrienne Moore, DrPH, said prior authorization has to strike the right balance, adding that it is an important tool in preventing medically unnecessary care, but the process can delay or prevent care and create significant administrative burden. She said clinical guidelines should be used in place of prior authorization when appropriate.
“There is a place for prior authorization, but it should not be our first or only option for clinical decision-making,” Dr. Moore said. “For example, we recently worked with Blue Cross of Arizona to provide gold-card status to all Banner providers so that authorizations are automated. Our providers must adhere to clinical guidelines and periodic audits are done to ensure efficacy.”
