Medicare Rights Urges Congress to Protect Beneficiary Access to Care

Today, the Senate voted on a measure (S.J. Res 198) to block the six-year Wasteful and Inappropriate Service Reduction (WISeR) model. While it failed to pass (46-50), the vote highlights mounting concerns with the model and presents opportunities for advocates to encourage policymaker intervention.

Launched by the Centers for Medicare & Medicaid Services (CMS) in January 2026 to test the expanded use of prior authorization and artificial intelligence (AI) in Original Medicare (OM), WISeR is currently operating in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington.

Stakeholders including providers, hospitals, and beneficiary advocates have expressed hesitation about the model’s aims, structure, and potential impact on access to care.

From the outset, stakeholders including providers, hospitals, and beneficiary advocates have expressed hesitation about the model’s aims, structure, and potential impact on access to care. Chief among these concerns is that WISeR introduces the type of prior authorization typically seen in private Medicare Advantage (MA) plans into the fee-for-service program and relies heavily on AI to make critical coverage decisions. It also creates perverse incentives: The AI contractors can share in savings that result from the care they deny. Reporting in the initial months of implementation confirms care disruptions and delays, which will likely intensify if the model stays in place.

Prior Authorization and Beneficiary Impacts

Prior authorization is a plan-imposed restriction that requires a beneficiary, usually through their provider, to obtain advance approval for a service to be covered. Intended to promote the delivery of high-value care, it can be misused and otherwise interfere with medically necessary treatments, leading to worse enrollee health and outcomes.

Coverage denials that result from prior authorization can impede timely access to care by forcing beneficiaries to choose between seeking other treatments, paying out of pocket, going without, or getting embroiled in the daunting MA appeals system.

Reports consistently indicate inappropriate denials unnecessarily force millions of beneficiaries into this cycle each year. This echoes our own experiences. Last year, as in previous years, questions about denials accounted for nearly one-third of all calls to the Medicare Rights helpline. Callers are often struggling with what to do next, from trying to unpack confusing plan communications to navigating a complex appeals process.

Even successful appeals come at a cost, including care delays and negative health outcomes.

Too often, there is not a simple solution. Appealing coverage denials is burdensome and time-consuming. Medicare Rights frequently hears from people who don’t know how to begin and from those who can’t; they don’t have time to wait for care or wade through what might be a thicket of denials across their care. Importantly, even successful appeals come at a cost, including care delays and negative health outcomes.

AI Tools in Medicare Decision-Making

Although AI has potential in some areas, it is not infallible, well understood, or always safe. Its use in the WISeR model context is particularly worrisome, as medical decisions must be between patients and providers, not outsourced to third-party contractors, algorithms, or other external actors.

Where AI has been used in Medicare, there has been minimal transparency and no accountability.

These concerns are grounded in experience. To date, where AI has been used in Medicare, there has been minimal transparency and no accountability. MA plans’ use of AI or algorithmic-driven software to make coverage decisions has created significant barriers to care, which are at risk of being replicated in OM through the WISeR model. Indeed, early reports note the rollout has caused confusion and delays in several states, from denials that conflict with coverage guidelines to decision timelines that exceed federal rules. These issues demonstrate that AI is not ready to be used in an unmonitored way, in high-stakes situations, or where its results cannot be fact checked, reliably duplicated, or clearly explained.

Inadequate federal and state AI regulation, as well as the lack of public trust in its accuracy, privacy, safety, and security, likewise indicate it is premature and inappropriate to give AI programs and vendors access to millions of Medicare beneficiaries and their personal information.

Policymakers Push Back on WISeR

As KFF notes, “The rollout of the WISeR model comes at a time when roughly seven in ten US adults with health insurance (69%) say that prior authorization is a burden, and more than a third (34%) say that it is their single biggest burden, beyond costs, when it comes to getting health care.”

Policymakers have registered opposition to WISeR in hearings, statements, and floor actions.

Recognizing these concerns, policymakers have registered opposition to WISeR in hearings, statements, and floor actions. Last year, lawmakers in both chambers introduced legislation to bar the model (H.R. 5940/S. 3480). Separately, the House Appropriations Committee adopted an amendment to prohibit spending on the model’s implementation. Though it was ultimately not included in the final 2026 spending bill, on June 9 the Committee unanimously approved adding similar language to the 2027 funding bill.

The House amendment comes on the heels of a May 20 effort led by House and Senate Democrats to block WISeR. Bolstered by a U.S. Government Accountability Office (GAO) finding, they argue the model is technically a “rule” for purposes of complying with the Congressional Review Act and therefore should have been submitted to Congress prior to its implementation. The Senate vote on this resolution (S.J. Res 198) earlier today fell short, keeping the model intact.

Beneficiary Stakeholder Concerns Grow

In a letter last month, in coalition with the Leadership Council of Aging Organizations (LCAO) Medicare Rights urged lawmakers to nullify the WISeR model. In part, we cited specific beneficiary harms that could result due to the services targeted by WISeR’s prior authorization expansion, as well as the program’s opacity:

“Recent reports indicate that the program may be harming Medicare beneficiaries and undermining their ability to manage chronic and painful conditions. For example, WISeR targets epidural steroid injections, procedures relied on by a significant number of beneficiaries to manage chronic spinal pain. Chronic pain in older adults is linked to serious negative outcomes, such as prolonged suffering, social withdrawal, reduced mobility, and increased strain on the healthcare system.

WISeR also imposes barriers to access to the non-invasive nerve stimulations that enable beneficiaries with Parkinson’s Disease to maintain gait and balance and reduce medication burden. Delays in access and denials of care for older adults needing these and other procedures subject to WISeR increase beneficiaries’ risks of disability and potentially worsen their underlying conditions.

We are also concerned about the lack of transparency with respect to implementation of the model. For example, it is not clear whether CMS plans to make available data on claims denial rates and re-submissions of claims; algorithms used for artificial intelligence determinations; the amounts of incentive ‘savings’ payments to participating companies; the results of CMS audits of company participants or reviews of adverse impacts on beneficiary health.”

Congress Must Protect Beneficiaries

Medicare Rights urges lawmakers to support efforts to curtail the WISeR model. The risk to beneficiaries is simply too great.

Read more about the WISeR model from CMS.

Read more from Medicare Rights about AI in Medicare.