CMS official concedes parts of Medicare's AI prior auth pilot WISeR are failing

Speaking at the ADAPT conference in Santa Fe, New Mexico on 15 October, CMS Deputy Administrator Kimberly Brandt told the audience that WISeR has real problems, as Nextgov/FCW reported and Medical Daily followed up. She did not specify which parts of the model are falling short.

"There are a lot of things about WISeR that are not working." Kimberly Brandt, Deputy Administrator, CMS

What WISeR is

WISeR, the Wasteful and Inappropriate Service Reduction model, brings prior authorisation into Original Medicare for a set of outpatient services that CMS regards as low value or open to fraud and abuse. Contractors use technology such as AI to screen requests, and a human clinician must review every denial, according to a Congressional Research Service overview. It applies to traditional Medicare, not Medicare Advantage.

The model started on 1 January 2026 and is due to run to the end of 2031 in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington, states that are home to about 6.4 million Medicare beneficiaries, the CRS says. Covered services include nerve stimulation, steroid injections for pain, cervical fusion and knee arthroscopy for osteoarthritis.

What CMS says it has learned

Brandt's slides set out the agency's lessons so far, Nextgov/FCW reports: the technology needs ongoing oversight, human clinical review is essential, and feedback from providers is an important signal to monitor. She said Innovation Center staff were committed to improving the programme, particularly with Congress watching closely.

A rocky first year

Complaints started early. In June, KFF Health News described confusion, errors and a payment backlog, naming Humata Health and Zyter among the vendors involved and quoting one Tulsa radiologist reporting six to eight week delays. The House Appropriations Committee voted in June to block funding for the pilot, but in July the Senate rejected a resolution to overturn it by 46 votes to 50, as Healthcare Finance News reported.

CMS has not yet published a full public evaluation, so the rate of reversed denials and the scale of harmful delays are not known.

The bigger picture

WISeR is the federal government's most visible test of AI in prior authorisation. An admission from a senior official that much of it is not working is likely to sharpen questions from providers and lawmakers about how AI-assisted decisions are overseen, just as electronic prior auth requirements for other government programmes arrive in January 2027.