Medicare Is Now Using Artificial Intelligence to Review Prior Authorizations. Here Is What Providers Need to Know.
Medicare's WISeR Model brings artificial intelligence review to prior authorization in six states. A PA-C explains the 15 services, the vendors, and what providers should do.
On January 1, 2026, something genuinely new started inside traditional Medicare. In six states, a list of medical services now requires prior authorization before Medicare will pay for them. The reviews are run by private technology companies using artificial intelligence. And those companies earn more when care gets denied.
That last sentence is not an exaggeration, and I will back it up below. The program is called the Wasteful and Inappropriate Service Reduction Model, which the federal Medicare agency shortens to WISeR. If you practice in Arizona, New Jersey, Ohio, Oklahoma, Texas, or Washington, this program already applies to you. If you practice anywhere else, I would still pay attention. Pilot programs that save money tend to expand.
What Is the WISeR Model?
The Wasteful and Inappropriate Service Reduction Model is a pilot from the Center for Medicare and Medicaid Innovation, the part of the Centers for Medicare and Medicaid Services that tests new payment ideas. It launched January 1, 2026 and is scheduled to run six performance years, through December 31, 2031.
The stated goal is reasonable on its face. Federal officials identified a set of services they consider prone to overuse, fraud, or marginal clinical benefit, and they estimated that spending on this kind of low-value care reached somewhere between 1.9 and 5.8 billion dollars in 2022 alone. Rather than reviewing claims after payment, Medicare now checks these services before they happen, the way commercial insurers and Medicare Advantage plans have done for years.
Here is the part that makes this pilot different from anything traditional Medicare has done before. The reviews are not performed by Medicare’s usual contractors. They are performed by six private technology companies, each assigned to one state, using artificial intelligence and machine learning to screen requests. The agency says a qualified human clinician makes every final denial decision, not the software. Whether that holds up in practice is one of the central questions hanging over the program right now.
Which States Are in the WISeR Model, and Who Reviews the Requests?
Six companies were announced in late 2025, each handling one state. If you practice in one of these states, the name on the right is the company reviewing your Medicare prior authorization requests.
| State | Reviewer |
|---|---|
| Arizona | Zyter |
| New Jersey | Genzeon |
| Ohio | Innovaccer |
| Oklahoma | Humata Health |
| Texas | Cohere Health |
| Washington | Virtix Health |
One important clarification, because I have seen this confused repeatedly. This program applies to traditional fee-for-service Medicare. Medicare Advantage plans already run their own prior authorization programs under separate rules, and those are not part of WISeR.
The 15 Services That Now Require Prior Authorization
The model targets 15 categories of items and services. Emergency services are excluded, as are inpatient-only procedures and anything where a delay would put a patient at substantial risk. The list leans heavily toward wound care products, implanted nerve stimulators, and a handful of musculoskeletal procedures.
Services subject to prior authorization under the WISeR Model, by category. Source: Centers for Medicare and Medicaid Services; American Society of Anesthesiologists.
| Category | Services on the list |
|---|---|
| Wound care | Bioengineered skin substitutes for chronic lower extremity wounds; cellular and tissue-based wound products for the lower extremities |
| Nerve stimulators | Electrical nerve stimulators; vagus nerve stimulation; phrenic nerve stimulators; sacral nerve stimulation; hypoglossal nerve stimulation for obstructive sleep apnea; induced lesions of nerve tracts |
| Spine and joint procedures | Arthroscopic lavage and debridement for the osteoarthritic knee; percutaneous image-guided lumbar decompression for spinal stenosis; percutaneous vertebral augmentation for compression fractures; epidural steroid injections for pain management; cervical fusion |
| Urologic and other devices | Incontinence control devices; diagnosis and treatment of impotence |
If you bill for any of these in the six pilot states, you have two options. You can submit a prior authorization request before providing the service. Or you can skip the request and provide the service anyway, in which case the claim goes through pre-payment medical review before Medicare pays. Skipping the request does not get you out of the review. It just moves the review to after you have already done the work, which in my view is the worse position to be in. An approved authorization is valid for 120 days.
The Incentive Problem Everyone Is Worried About
The design choice drawing the most fire is how the vendors get paid. They receive a share of the savings generated when care is averted. The American Heart Association has stated that participating vendors will be compensated with roughly 10 to 20 percent of the savings associated with denials. The American Hospital Association called the structure inherently biased and compared it directly to the MultiPlan arrangement, where a private firm’s fees were tied to claim reductions. That arrangement became the subject of a New York Times investigation and ongoing federal antitrust litigation.
A company that earns a percentage of every denied dollar has exactly one financial reason to exist. I have not seen anyone in the agency explain convincingly why this program will be the exception.
To be fair to the other side of the argument, the services on the list were not picked at random. Several have weak or genuinely contested evidence behind them, and federal estimates put the waste in the billions. Skin substitute spending in particular has exploded in ways that are hard to defend clinically. There is a real problem here worth solving. My concern, and the concern of most of the physician organizations that have weighed in, is that paying reviewers per denial is a tool that does not distinguish between cutting waste and cutting care.
The Lawsuit, the Repeal Bill, and What Providers Are Reporting
Opposition arrived fast. In November 2025, a bipartisan group of House members introduced legislation to repeal the model outright. Representative Frank Pallone of New Jersey, the ranking Democrat on the House Energy and Commerce Committee, said he was concerned the program will result in denials of lifesaving care and incentivize companies to restrict care.
The Electronic Frontier Foundation, a digital rights group, has sued the agency seeking records about how the artificial intelligence actually works. The suit asks what data trained the algorithms, what safeguards exist against bias and improper denials, and what financial incentives the vendors operate under. The fact that those questions require litigation to answer tells you something about how much has been disclosed voluntarily, which is very little.
Meanwhile, reporting from the pilot states in the first five months has not been encouraging. Coverage from public radio stations in Washington state described seniors facing denied and delayed care under the new reviews. Medscape reported in the spring that physicians in pilot states are seeing more denials and longer waits for peer-to-peer reviews, with several medical societies confirming similar reports from their members. Some Washington physicians have openly questioned whether a trained clinician is actually reviewing the cases, given the nature of the denials coming back.
None of this surprises me, and I say that as someone who handles prior authorizations in a clinic, not as an observer. Physicians were already bracing for this. In the American Medical Association’s 2025 survey of one thousand physicians, six in ten said they were worried artificial intelligence would increase denial rates. The rest of that survey is worth seeing in one place.
What physicians say about prior authorization (2025)
| Physicians surveyed who… | Share |
|---|---|
| Say it contributes to physician burnout | 94% |
| Say it delays patient care at least sometimes | 93% |
| Report denials increased over five years | 74% |
| Worry artificial intelligence will raise denials | 60% |
| Report a serious adverse event from the process | 26% |
What physicians told the American Medical Association in its 2025 prior authorization survey. Chart: Benjamin Hillman, PA-C. Data: American Medical Association, 2025 Prior Authorization Physician Survey.
Those numbers describe the system WISeR was added to. Physicians and their staff already spend about 13 hours a week on prior authorization paperwork, completing an average of 40 requests per physician per week. More than one in four physicians reported the process has led to a serious adverse event for a patient in their care, including hospitalization, permanent harm, or death. Layering an artificial intelligence reviewer with a financial stake in denials on top of that baseline is, I think, a strange way to reduce administrative burden.
How the Pilot Is Supposed to Unfold
- June 2025 Federal officials announce the WISeR Model and identify the targeted services.
- November 2025 The six review vendors are named. A bipartisan repeal bill is introduced in the House.
- January 1, 2026 Prior authorization begins for the 15 services in all six states.
- Mid-2026 (expected) Exemptions for providers with consistently approved requests, often called gold carding, are expected to roll out.
- December 31, 2031 The model’s six performance years end, unless Congress ends it sooner or the agency expands it.
What Providers in the Six States Should Do Now
My Honest Read
I want to be careful here, because the easy take is that this is simply Medicare adopting the worst habits of commercial insurance. The truth is messier. The targeted services include real waste, the kind that costs taxpayers billions and exposes patients to procedures with thin evidence. Some form of scrutiny was coming, and frankly some of it was overdue.
But the structure matters more than the intent. We have years of evidence from Medicare Advantage showing what happens when reviewers are rewarded for saying no. Denial rates climb, most denials are never appealed, and when patients do appeal, the overwhelming majority of denials get overturned. Building a new program on that same incentive, then adding software that can generate denials at machine speed, is a bet that this time will be different. The early reports from the six pilot states suggest it is not different. Watch this one closely even if you practice somewhere else, because if it survives the lawsuits and the repeal effort, your state is probably next.
Sources
- WISeR (Wasteful and Inappropriate Service Reduction) Model — Centers for Medicare and Medicaid Services
- Meet the 6 vendors participating in the WISeR Model — TechTarget
- WISeR Services, Procedure Categories, and Billing Codes — American Society of Anesthesiologists
- Hypoglossal Nerve Stimulation and Medicare’s WISeR Model — American Academy of Otolaryngology
- New WISeR Model Revives Concerns of Prior Authorization and Artificial Intelligence — Georgetown University Medicare Policy Initiative
- Medicare’s new artificial intelligence experiment sparks alarm among doctors, lawmakers — Stateline
- Physicians, Lawsuit Challenge Medicare’s WISeR Prior Authorization Experiment — Medscape
- Washington seniors face denied, delayed care under artificial intelligence Medicare review program — Oregon Public Broadcasting
- Lawsuit challenges the WISeR prior authorization model — American Academy of Sleep Medicine
- Electronic Frontier Foundation sues Medicare agency over prior authorization artificial intelligence — HealthExec
- Medicare Is Using Artificial Intelligence for Prior Authorization; Democrats Want It to Stop — Newsweek
- WISeR Model: What Providers Need to Know by January 2026 — Forvis Mazars
- 2025 Prior Authorization Physician Survey — American Medical Association
- Medicare Advantage Insurers Made Nearly 53 Million Prior Authorization Determinations in 2024 — KFF