Policy Watch
Since January 1, 2026, Medicare patients in six states have had their care requests evaluated by an AI system called WISeR — the Wasteful and Inappropriate Service Reduction model, a CMS pilot active in New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington. The program screens Medicare prior authorization requests for services deemed “low-value,” and it compensates its private vendor contractors with up to 20% of the value of services denied. In Texas, initial approval rates under WISeR were 62%, far below the 92% national Medicare Advantage baseline — with most rejections reversed only after human review.
Why the incentive structure is drawing scrutiny
The WISeR payment structure — compensating contractors based on a share of “savings” generated by service denials — is the feature drawing the sharpest legal and policy criticism. Critics argue this design creates a direct financial incentive to deny medically necessary care, regardless of the algorithm’s accuracy. The Electronic Frontier Foundation filed a FOIA lawsuit against CMS in 2026 demanding disclosure of the algorithm’s training data, bias testing methodology, and internal audit results. CMS has not complied. The American Academy of Sleep Medicine and multiple health advocacy organizations have filed their own legal challenges.
What Medicare patients need to know
Medicare beneficiaries whose care requests are screened by WISeR have no practical way to know an algorithm evaluated their case. The notice they receive, if any, describes a denial and an appeal right — not the AI process that generated it. For patients seeking remote patient monitoring, telehealth services, or home health authorization in the six pilot states, this means a computer system with undisclosed accuracy rates and no publicly audited bias controls may determine whether their care is initially approved.
The political fault lines
Opposition to WISeR cuts across political lines in an unusual way. Critics on the left argue it enables opaque, incentive-distorted AI denial of care — particularly harmful to low-income beneficiaries with fewer resources to navigate appeals. Critics on the right frame it as an unaccountable, non-transparent federal regulatory experiment applied to Medicare patients without meaningful congressional authorization. What is notable is that CMS launched this pilot under existing administrative authority, without specific statutory direction — and that the agency’s disclosure to affected patients has been minimal.