This past summer CMS, more specifically CMMI, announced a six-year Medicare Part A demonstration that would require hospitals in six states to submit claims for prior authorization (PA) approval by non-medical, CMS-contracted, 3rd party entities using enhanced technologies, i.e., AI, for 17 medical items and services. Private/commercial Medicare or Part C Medicare Advantage plans have for years extensively used PAs though data suggests Medicare Advantage PA use has been excessive, e.g., a very high percentage of PA denials are reversed upon appeal) and widely viewed as a tool to enhance profit taking. CMMI-contracted tech/AI companies will be compensated based on a share the money saved from PAs contractors’ deny though subject to meeting quality criteria. The WISeR demo has attached a fair amount of criticism, e.g., 12 Senate Democrats and 17 House Democrats each wrote letters to HHS/CMMI noting their concerns that include the demo will present patient roadblocks, cause some patients to abandon care, risk denying necessary care, inflict substantial administrative burden on clinicians, perversely incent AI contractors and they argued Americans do not want AI involved in their healthcare decisions.
The July 1 Federal Register WISeR notice is at: https://www.govinfo.gov/content/pkg/FR-2025-07-01/pdf/2025-12195.pdf.
The CMS/CMMI WISeR website is at: https://www.cms.gov/priorities/innovation/innovation-models/wiser.
Liu and Wadhera’s NEJM Perspective essay re: the WISeR demo is at: https://www.nejm.org/doi/abs/10.1056/NEJMp2510451.
Don Berwick and Andrea Ducas’s STAT opinion essay re: the WISeR demo is at: https://www.statnews.com/2025/07/25/medicare-advantage-prior-authorization-cms-innovation-center-wiser-project/.
