WISeR Model Raises Serious Concerns for Patients and Providers
Efforts to reduce fraud, waste, and abuse in Medicare are important and necessary. However, recent developments surrounding the WISeR (Wasteful and Inappropriate Service Reduction) Model raise significant concerns about unintended consequences -particularly for patients enrolled in Traditional Medicare who have long relied on predictable access to care.
Members of Congress recently expressed alarm that the WISeR model expands prior authorization into Traditional Medicare, a system historically trusted by beneficiaries because it minimizes administrative barriers and allows patients to receive timely, medically necessary care. Those concerns are no longer theoretical - they are already affecting patients.
A Patient Story That Illustrates the Impact
A Medicare patient in our practice was scheduled for a medically necessary surgical procedure. Under the WISeR model, while the physician codes did not require prior authorization the (hospital codes) procedure became subject to prior authorization or pre-payment medical review. Because authorization was not finalized in time, the patient was informed that her surgery may need to be rescheduled.
The patient was understandably distressed. She shared that her two daughters had already taken time off work to travel and help with post-operative care. A delay would not only postpone treatment but also disrupt family plans, increase emotional stress, and potentially create financial hardship.
This is not an isolated administrative inconvenience - it is a patient access issue.
Provider Frustrations
Providers are spending more time on peer-to-peer reviews which are rising after automated denials. The U.S. Senate Permanent Subcommittee on Investigations has raised concerns that the AI tools have been accused of producing high rates of care denial-in some cases 16 times higher than typical. With the introduction of the CMS WISeR model and AI-assisted utilization management, physicians and hospital systems have growing and well-founded concerns regarding increased denials, administrative burden, and potential delays in patient care.
Why This Matters
In a July 31, 2025 letter to the Centers for Medicare & Medicaid Services, members of Congress (Reps. Alexandria Ocasio-Cortez (NY-14) and Lloyd Doggett (TX-37), along with 40 colleagues), noted that prior authorization can delay care and deny medically necessary services, with studies showing that a significant percentage of denials are later overturned on appeal. Despite this, the WISeR model introduces prior authorization into Traditional Medicare and places decision-making authority in the hands of for-profit entities, some of which may be compensated based on “averted expenditures” - a structure that risks incentivizing denials rather than appropriate care.
Equally concerning is the potential use of artificial intelligence tools to determine medical necessity, often without transparency into how those decisions are made. Patients and physicians may be left navigating opaque systems with little recourse, even when care is clearly warranted.
Preserving the Promise of Traditional Medicare
Traditional Medicare has earned strong patient satisfaction because it offers stability, broad access, and fewer barriers to care. Introducing prior authorization requirements -especially for already scheduled and medically necessary procedures - undermines that trust and shifts the burden onto patients, families, and physician practices.
Safeguards to protect taxpayer dollars are essential, but policies must be designed in a way that does not delay care, disrupt families, or erode the core strengths of Traditional Medicare. As the WISeR model moves forward, patient stories like this one should serve as a warning: reforms that look reasonable on paper can have very real - and very personal -consequences.
Healthcare policy should protect patients first. Any effort to reduce waste must do so without compromising access, predictability, and timely care for the seniors who depend on Medicare.