The Wasteful and Inappropriate Service Reduction (WISeR) Model, a six-year demonstration testing the use of artificial intelligence-enabled prior authorization for selected Part B services in traditional Medicare across six states, will continue for now after the Senate defeated a Congressional Review Act resolution that sought to terminate the program.

The House, however, has a different view of the program with a bipartisan group of legislators who believe the program requires more Congressional oversight and transparency, and who have heard concerns that beneficiaries in traditional Medicare are being denied needed care under the model.

In early June, the House Appropriations Committee adopted a bipartisan amendment to the Fiscal Year (FY) 2027 Labor-HHS- Education (Labor-H) appropriations bill (HR 9260), where the committee voted to prohibit the Centers for Medicare and Medicaid Services (CMS) from using any appropriated funds for the WISeR model or similar effort to implement prior authorization in Medicare. With this effective termination of the program in the House Labor-H appropriations bill, the debate is not over and will become part of the appropriations negotiations between the House and Senate.

It is important to note that WISeR is a demonstration and currently limited to Part B services. There is no indication at this time that it will be expanded to Part A services nor to additional state. To expand the program, there would need to be evidence that the program was successful at reducing costs and improving outcomes.

One area that WISeR has been targeting is skin substitutes, which LeadingAge hospice providers have flagged as a concern for fraud. While there has been a decline in their use, it remains unclear whether this is the result of the WISeR model or other policy changes to the physician fee schedule. To read more on the WISeR model, view this LeadingAge article.

While LeadingAge doesn’t outright oppose prior authorization or the use of artificial intelligence (AI) , it believes the use of prior authorization and AI requires appropriate guardrails and oversight to ensure it is not used to inappropriately burden providers nor delay or deny needed care and services for older adults in both traditional Medicare and the Medicare Advantage (MA) program. Therefore, like in MA, we agree the WISeR demonstration model could benefit from more oversight and transparency to protect Medicare beneficiaries and ensure inappropriate barriers to services don’t result.

There are many more steps in the political process before this issue will be decided about whether prior authorizations in traditional Medicare can continue through the WISeR model.