The Medicare WISeR experiment. I wasn't aware of this. In case you aren't either, here's the f-ed up deal:

[pat_k]

They are degrading original Medicare Part A and Part B in six states as part of a Center for Medicare and Medicaid (CMS) Wasteful and Inappropriate Service Reduction (WISeR) experiment.

The "incentive structure" shovels a share of the dollars "saved" into the pockets of the technology companies participating in the program.

The six states are Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington (where I live).

The short story is that, in these states, pre-authorization will be required for "targeted services" that are currently covered under Part A and Part B.

This will affect people who keep their Part A and B and purchase a supplement to cover out of pocket costs. Republicans have successfully degraded Medcare Advantage Plans, but have not been able to touch Original Part A and Part B. This sure sounds to me like a "back door" attempt to degrade original medicare with the added bonus of shoveling public funds into the pockets of "technology companies."

The authority under which this program is being implemented is Section 1115A of the Social Security Act.

Some Qs and AI answers

What technology companies are participating?

Specific participating technology companies for the Medicare WISeR (Wasteful and Inappropriate Service Reduction) model are not yet publicly listed as the program is new, but they will be health technology companies using AI and machine learning to manage prior authorization for services like skin and tissue substitutes, electrical nerve stimulators, and knee arthroscopy.

By what authority is CMS implementing this program?

CMS is implementing its Wasteful and Inappropriate Service Reduction (WISeR) Model under the authority of Section 1115A of the Social Security Act. This act created the Center for Medicare & Medicaid Innovation (CMMI), which is authorized to test innovative payment and service delivery models in Medicare and Medicaid to reduce costs while preserving or improving quality of care. The WISeR model, a six-year pilot program beginning January 1, 2026, uses technology-driven prior authorization to target specific services in Original Medicare that have been identified as potentially wasteful or inappropriate.

It sure sounds to me like denying care that was previously covered absolutely violates the requirement of these programs to "preserve" or "improve" care.

Are there any lawsuits against the CMS for violating Section 1115A of the Social Security Act?

No lawsuits have been filed against CMS for the WISeR Model as of late September 2025, but several professional medical societies and lawmakers have expressed strong opposition and concern through letters to CMS due to potential risks of delayed care and increased administrative burdens. While formal legal action hasn't been taken, the significant backlash from key stakeholders suggests the possibility of future litigation if the model's concerns are not adequately addressed by CMS.

An overview of CMS's WISeR program

The model targets specific outpatient services deemed to have limited clinical benefit or be vulnerable to waste, such as certain skin and tissue substitutes and knee arthroscopy for osteoarthritis. Technology companies use artificial intelligence and machine learning to help licensed clinicians assess requests, with participants earning a share of the savings generated by identifying medically unnecessary services.

Targeted Services: The model focuses on specific items and services that may pose patient safety risks if delivered incorrectly or have a history of fraud, waste, and abuse, including certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) and specific musculoskeletal procedures.
Technology Integration: The program leverages AI and ML technology from participating tech companies to assist clinicians in assessing the medical necessity and appropriateness of services.

Incentive Structure: Model participants (technology companies) earn a share of the savings generated by identifying medically unnecessary services.

Review Process: All determinations are made by licensed clinicians using evidence-based criteria to ensure fairness and accuracy.

Exclusions: The WISeR Model excludes inpatient-only services, emergency services, and services that would pose a significant patient risk if significantly delayed.

How were the states selected?

CMS picked six states—Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington—for the Wasteful and Inappropriate Service Reduction (WISeR) model based on a combination of evaluability and operational criteria, including selecting within the same Medicare Administrative Contractor (MAC) jurisdictions to allow for direct comparison between test and comparison states, choosing states with sufficient claims volume for reliable impact estimates, and prioritizing states with existing administrative contractors that already had coverage policies for the targeted services.

Here's a breakdown of the selection criteria and process:

MAC Jurisdictions: The model was assigned to four MAC jurisdictions: JH, JL, JF, and J15.

Within-MAC Comparisons: CMS selected states within the same MAC jurisdictions so they could compare the test states to other states within that same MAC.

Adequate Claims Volume: States were chosen for their sufficient volume of claims, which allows for precise estimates of the model's impact.

Existing Coverage Policies: CMS prioritized states where the administrative contractors already had coverage policies for the services targeted by the model.

Geographic Diversity: The selected states represent diverse geographic areas.

Highest Historical Claim Paid Amounts: States meeting the evaluation criteria were also selected based on the highest historical claim paid amounts.

[Nigrum Cattus]

1. another way to transfer public money

to private companies. A.I. is not the way
to justify treatments.

[pat_k]

4. Tech Co's getting a share of the money saved by denying services. What could possibly go wrong??

According to this article, "Medicare has historically used prior authorization in a limited way, with contractors who aren’t incentivized to deny services."

If there is an actual need for prior authorization, payment for processing should absolutely NOT be tied to denial of service if you actually want to serve Medicare recipients.

The article also notes that WISer "ultimately depends on contractors to assess their own results, a choice that makes the results potentially suspect."

So, these technology company contractors, who are incentivized for denying care, are also responsible for assessing their own results???!!!

With that combination, they practically guarantee harm to patients and theft of public funds.

[leftstreet]

2. JFC

They just won't stop until all they've privatized all of Medicare

Then we'll hear "MEDICARE FOR ALL"

[vapor2]

5. YUP, Bessent , Oz and other repugs want to privitaze it

ALL FOR THE EFFN BILLIONAIRES. I just want to leave this shit hole we're in.

[pat_k]

11. I know they'd love to privatize, but there's something else behind this particular move (like enriching tech bros)

There's a lot of dollars floating around in the Medicare system. This is just one of the ways they've come up with to siphon some off for them own selves. I have little doubt we'll see some other unprecedented "reforms" coming out of CMS under the guise of "improving" care.

Strangely, just a couple months ago wasn't Oz talking about the evils of prior authorization and how insurance companies needed to cut the red tape? And now they turn around and add it to a system that has been doing fine with very limited use of prior authorization?

Nothing adds up with these crooks.

[Bayard]

3. My hair can only take being set on fire so many times

The only people this is good for are the tech companies. We know they will not approve anything because it puts money in their pockets. AI is going to decide who gets the medical care they need. Anything that eats into profits will be deemed wasteful.

Wonder how many of my specialists I would lose if this makes it to KY. I better push Mr. Bayard harder to get those knees replaced now.

[Ms. Toad]

6. This has nothing to do with who you see.

It is requiring pre-authorization for a limited number of services (regardless of who performs them).

It is horrendous - and (despite the assertions of at least one DU member to the contrary) targets services (17-ish) which are legitimate medical services (not things which might be abused because they are cosmetic, for example). I have had one of those services (skin graft following cancer). Had a denial been imposed, which would have delayed surgery to remove the tumor for a month or more. The tumor doubled in 17 days, so leaving it a month (or more) longer would likely mean I would no longer be alive. So, yeah, it's personal for me.

But, as bad as it is, knee replacements are not included in the services, nor is your right to see any physician who has not opted completely out of Medicare.

[pnwmom]

10. Another two procedures were used in my husband's cancer treatment.

The idea of incentivizing these tech companies by giving them a share of the "savings" is despicable.

[Ms. Toad]

17. Agreed.

Unlike the existing decisions which are (primarily) dual cosmetic and medical procedures (e.g. blepharoplasty - sought largely for cosmetic reasons, but also medically necessary when the eyelid droops far enough into the line of vision to limit vision), these new 17 are medical procedures - and the decision to use them (or not) should be a decision between the patient and the doctor.

[lostnfound]

15. Just the first step which will end up with terrible care and programmable death panels / delays for profit

look at United “HealthCare” which gave kickbacks to nursing homes for signing residents up for Medicare Advantage, getting residents to sign DNR orders and for not taking residents to hospital.

[Ms. Toad]

16. As I said - I think it is horrendous.

BUT it is limited to 6 states for 17 procedures.

Medicare already requires pre-approval (in all 50 states) for around 50 outpatient procedures.

The difference here is that the 17 procedures aren't ones which overlap with cosmetic procedures (unlike the vast majority of the 50 current ones), and that the pre-approval is being done by AI by companies which have a profit motive to deny them.

[pat_k]

7. I don't buy for a second that three months before implementation they haven't...

... identified the tech companies that will be involved.

Of course they know who they are. They are just buying time before making the entities public for cronies to get on board as investors in this boondoggle.

As Oliver Kornetzke points out in this article,

There’s no grand ideology. There’s only theft. Power is just a means to steal more...

...Trump, a failed businessman and serial conman, didn’t stumble into power because he had a vision. He stumbled into it like a raccoon into a jewelry store: overwhelmed, opportunistic, and desperate to grab everything shiny before the lights come on. He brought with him a gang of similarly hollow, self-serving goons—parasites in flag pins—who recognized that brute force and spectacle could serve as a perfect cover for mass-scale corruption. All they needed was enough boots, enough masks, and enough Americans too scared or too exhausted to resist.

That’s what ICE is now—a terror squad designed not just to punish the “other,” but to frighten the rest into submission. They don’t need to knock on your door. They just need you to see what happens when they knock on hers. They want you disoriented, enraged, heartbroken, and above all—silent.

It’s not about immigration. It’s about domination...

[yonder]

8. This a BFD.

A foot in the door to crack the armor of Medicare as we know it.

[pat_k]

9. My reaction too.

47 is happy to give Republicans a bone by "cracking the armor of Medicare," but ultimately, I think the real purpose is simply corrupt enrichment of himself or cronies. Doesn't matter who gets hurt.

As I noted in a previous post, I don't buy for a second that three months before they "go live" they don't know the names of the technology companies participating. Could be cronies are incorporating entities right now to cash in on the boondoggle.

As Oliver Kornetzke points out in this article,

There’s no grand ideology. There’s only theft. Power is just a means to steal more...

[Ms. Toad]

18. Yes and no.

Pre-approval is rare, but not new, for traditional Medicare. It is currently limited to around 50 outpatient procedures which are primarily cosmetic - but also occasionally medically necessary.

This new program adds 17 medical procedures, and farms pre-approval out to an AI company with a profit motive to deny procedures.

So the concept of pre-approval to weed out procedures which are not covered by Medicare (when used cosmetically) is not new - that armor cracked in 2020. Shifting to interfering with medical procedures which are covered, but which some morons decided were being abused, and farming out the pre-approval to a company with a profit motive is new.

I've written all my congress critters about my concerns, objecting to the new program - using my personal example (I had one of the procedures which is subject to pre-approval in the state in which I live, come January - AND - if the procedure had been denied it would have delayed surgery long enough for my cancer to metastasize, rather than being restrained to a local tumor . . . with the kicker that my insurance company denied payment for the procedure after the fact, so it is likely that had I been on Medicare with pre-approval required at the time some AI-bot would also likely have denied it. It was approved on appeal, but the time for the appeal was months.) I hope you will do the same - even if it isn't incredibly effective, communicating with congress-critters is more effective than posting on DU.

[Tanuki]

12. UnitedHealth's foray into using AI in this manner

was an unmitigated disaster.

https://www.google.com/amp/s/www.cbsnews.com/amp/news/unitedhealth-lawsuit-ai-deny-claims-medicare-advantage-health-insurance-denials/

"The families of two now-deceased former beneficiaries of UnitedHealth have filed a lawsuit against the health care giant, alleging it knowingly used a faulty artificial intelligence algorithm to deny elderly patients coverage for extended care deemed necessary by their doctors.

The lawsuit, filed last Tuesday in federal court in Minnesota, claims UnitedHealth illegally denied "elderly patients care owed to them under Medicare Advantage Plans" by deploying an AI model known by the company to have a 90% error rate, overriding determinations made by the patients' physicians that the expenses were medically necessary.

"The elderly are prematurely kicked out of care facilities nationwide or forced to deplete family savings to continue receiving necessary medical care, all because [UnitedHealth's] AI model 'disagrees' with their real live doctors' determinations," according to the complaint.
....
The use of the allegedly defective AI model, developed by NaviHealth and called "nH Predict," enabled the insurance company to "prematurely and in bad faith discontinue payment" to its elderly beneficiaries, causing them medical or financial hardships, the lawsuit states.
....
In their complaint, however, the families accuse UnitedHealth of using faulty AI to deny claims as part of a financial scheme to collect premiums without having to pay for coverage for elderly beneficiaries it believes lack the knowledge and resources "to appeal the erroneous AI-powered decisions."...(more)

[cliffside]

13. Every damn thing is about greed and the desire to amass more money :( nt

[pat_k]

14. Yep

https://www.democraticunderground.com/100220685580#post7