Patty’s Takes: Medicare’s WISeR payment model raises serious concerns

Our consumer protection mission includes running the Senior Medicare Patrol to help uncover fraud and abuse in the Medicare program and educate seniors about how to recognize fraud.

That’s a long way of saying we understand the importance of rooting out waste, fraud, and abuse, and the impact it can have on costs, access to care and the health of Medicare beneficiaries. And we support advancements that help uncover and fix fraud in our health care system because we know it impacts what we all pay.

That said, I have serious concerns about the recently announced federal Medicare fraud and abuse prevention pilot coming to Washington state next year.

Fighting fraud and abuse in our healthcare system is not the problem; it’s how the WISeR (Wasteful and Inappropriate Service Reduction) pilot model was rolled out and the questions it’s left unanswered.

Trump administration announces new pilot model

The Trump administration recently announced it’s launching a new payment and service delivery model, called WISeR, for six years in six states — including Washington — starting Jan. 1, 2026. WISeR only applies to Original Medicare and will require seniors get prior authorization on 17 procedures.

Under this new provider payment model, the companies the Centers for Medicare and Medicaid Services (CMS) contract with to pay claims will be allowed to use advanced technology, including Artificial Intelligence (AI) and Machine Learning, along with clinical review, to determine if certain claims should be paid. This alone increases the potential for unreasonable delays or denials of care and does absolutely nothing to address the main drivers of “waste, fraud and abuse” in our healthcare system, like upcoding.

Again, the new model will only apply to Original Medicare, not Medicare Advantage plans. Medicare Advantage plans already require prior authorization for most expensive services, but Original Medicare has only required prior approval for limited hospital outpatient services and some durable medical equipment — until now.

The new pilot model will require providers to get prior authorization for 17 services CMS has found to be costly and prone to abuse, including skin and tissue substitutes, nerve stimulators and stimulation devices, epidural steroid injections, cervical fusion, knee arthroscopy for osteoarthritis and 12 other services.

The model says final decisions on whether a provider is paid for a service will be made by licensed clinicians.

Here are some of my concerns:

· The pilot program claims timely decisions will be made but includes no specific response time for standard or expedited requests for prior approval.

• It says the clinical coverage criteria currently used in Original Medicare will be used, but there’s no details on how this would be automated, how algorithms would be developed or how machine learning and AI would be used in the process.
• A clinician with relevant clinical experience will review all unapproved requests, but there are no details on the standards for this review.
• CMS issued a federal rule that sets prior authorization standards for some Medicare and Medicaid plans to help lessen the administrative burden for providers. Our state adopted similar requirements for our commercial health plans. This pilot program moves in the opposite direction by creating more work for already stressed providers.
• And lastly, companies paying claims and doing the review will be paid based on a percentage of the money they save Medicare, appearing to reward the companies on the amount of care they prevent. We know from past experience that this often leads to inappropriate delays and denials.

My commitment to you

While this federal project is happening, we are in close contact with our Congressional delegation. We’ll be creating resources to educate people about their rights to appeal any prior authorization denial and to help answer your questions along the way.

We want to hear from you if you experience difficulties getting the care you need and will share your stories with your members of Congress.

This administration appears intent on doing everything in its power to restrict access to healthcare to the people of this country. But while they work to delay and deny care, we here in this Washington are working to expand access to quality, affordable healthcare. It is one of the best investments we can make with our tax dollars.