Key Takeaways
- Medicare’s new WISeR pilot program requires prior authorization for 13 specific services, using artificial intelligence to speed decisions and curb alleged fraud.
- Early implementation in six states has produced confusion, long wait times, payment delays, and frustration among patients and physicians.
- Providers report that the rollout was rushed, with many still learning the system while facing denials that sometimes appear to stem from AI errors.
- Although CMS asserts the process returns decisions within 72 hours and pays clean claims within 15 days, real‑world experiences show delays of weeks to months and growing appeals costs.
- Critics warn that the pilot could expand prior authorization to many more services, shifting costs onto patients and doctors rather than saving money for the system.
Patient Experience Highlights Early Challenges
Bill Curry, a 65‑year‑old cattle farmer from rural Oklahoma, has long made the 2½‑hour drive to Oklahoma City for epidural injections to treat his back pain. This year, however, the new Medicare WISeR model forced him to make additional trips. “In February, during one trip, he was told unexpectedly that he needed preapproval for the procedure. Then he went again a month or so later to get the injection, for a total of 10 hours on the road,” the article notes. Curry was later asked to return a third time simply “to fill out a piece of paper to tell them how you feel again,” a request he declined because it felt unnecessary. His experience illustrates how the pilot has turned routine care into a burdensome bureaucratic ordeal for many beneficiaries.
Program Design and Federal Rationale
Launched in mid‑January 2025, WISeR (the Wasteful and Inappropriate Service Reduction Model) applies prior authorization to 13 services deemed prone to fraud or misuse, including epidural injections, kyphoplasty, and skin substitutes. The program leans on artificial intelligence to review clinicians’ submissions and grant an “immediate yes” in roughly 88 % of cases that meet clinical criteria, according to Jeremy Friese, CEO of Humata Health, the vendor for Oklahoma. Medicare’s Abe Sutton, director of the Center for Medicare and Medicaid Innovation, said the goal is to ensure prior authorization is “efficient, fast, and streamlined,” adding, “The model aims to reduce inappropriate care without delaying appropriate care.” CMS Administrator Mehmet Oz echoed this sentiment, telling NewsNation that the initiative is “not to deny care” but to “make sure you get the care you need and deserve, not the care some unscrupulous doctor wants to use on you.”
Rapid Rollout Leads to Confusion
Providers and medical associations have criticized the speed of WISeR’s deployment. Todd Baker, former CEO of the Ohio State Medical Association, described the launch as “quicker than normal” for the federal government, noting that doctors “just sort of had to figure it out.” Jeb Shepard, director of policy at the Washington State Medical Association, agreed that the sudden change left clinicians scrambling. Jeremy Friese acknowledged that Humata Health faced “an aggressive rollout from the time of being notified to going live,” and executives in other states reported still adding features to their platforms in the spring. The hasty implementation left many practices without adequate training or support, contributing to early errors and frustration.
Delays, Denials, and Payment Backlogs
Despite CMS’s promise of 72‑hour decision turnarounds and 15‑day payments for clean claims, frontline reports paint a different picture. The University of Washington’s medical system had nearly 100 patients waiting for epidural injections earlier this year due to WISeR‑related delays, according to a Senate‑commissioned report. Jennifer Valle, a precertification supervisor at Clinical Radiology of Oklahoma, described “nitpicking” reviewers and instances where requested imaging was already in the file. James Webb, a musculoskeletal radiologist in Tulsa, said his practice has seen “six‑ to eight‑week delays” for kyphoplasty reimbursements, far beyond the promised timeline. Jerry Sobel, a Phoenix‑area pain‑management doctor, lamented that as of May he had not been paid for nine epidurals, calling the situation “horrendous” and citing a lack of organization from the outset.
AI Role and Suspected Errors
Although CMS vendors maintain that humans make the final approval decisions, many clinicians suspect artificial intelligence is driving denials, sometimes through “hallucinations” that invent or distort information. An Arizona doctor (who requested anonymity) recalled a denial stating his patient was ineligible for thoracic‑region procedures when the patient actually needed a neck injection. Webb documented four cases where a WISeR application was rejected for lacking numbness—yet the denial cited numbness as a reason to refuse the spinal surgery. Friese said he had not heard of any AI hallucinations, but the discrepancy between vendor assurances and clinician experiences fuels skepticism. The rise in denials has also spurred more appeals, increasing administrative costs for Medicare’s contractors, a factor Sutton acknowledged the agency has “accounted for.”
Policy Implications and Future Outlook
Health policy experts warn that the pilot may be a harbinger of broader prior‑authorization expansion. Miranda Yaver of the University of Pittsburgh observed that prior authorization often shifts costs onto patients and doctors through wait times and inconvenience rather than saving money for insurers. Mary Clarke, a family‑practice physician in Stillwater, Oklahoma, cautioned, “Everybody knows that if this pilot project works, it will be prior auth for basically all procedures… If they can show that they can save money, then that’s going to be extrapolated and rolled out to other procedures and multiple other things in other states.” When asked about expansion, Sutton replied that there are “currently no changes” considered for the list of services under WISeR, but CMS “continues to assess whether any changes are warranted.”
Conclusion and Call for Stories
The WISeR pilot illustrates the tension between curbing alleged fraud and preserving timely access to care for Medicare beneficiaries. While federal officials frame the initiative as a streamlined, cost‑saving tool, early adopters describe a process mired in confusion, delays, and potential AI‑driven errors that undermine its promised efficiency. As the program continues, stakeholders will watch closely to see whether adjustments can alleviate the burdens on patients like Bill Curry or whether the model will indeed spread to additional services, reshaping the landscape of Medicare care.
Readers who have experienced prior authorization under WISeR or other Medicare policies are invited to share their stories with KFF Health News by clicking the link provided in the original report.
https://www.cbsnews.com/news/medicare-ai-program-wiser-prior-authorization-errors-delays/