Big Deal: Lawmakers Sound the Alarm Against CMS’s WISeR Model
Lawmakers urge CMS to scrap a model they say will deny necessary treatment as bipartisan calls for MA reform grows.
A few weeks ago, Rachel Madley, PhD, director of policy and advocacy for the Center for Health & Democracy, laid out why the Centers for Medicare and Medicaid Services’ new Wasteful and Inappropriate Service Reduction (WISeR) Model is bad news for patients in Traditional Medicare. She warned that it would import one of the worst aspects of Medicare Advantage — aggressive prior authorization run by private, profit-driven contractors — into a program that has long prided itself on letting doctors, not algorithms, decide what’s medically necessary.
Madley’s piece explained why WISeR is dangerous:
It hands prior authorization in Traditional Medicare to private companies that profit by denying care — exactly as they do in MA.
It uses AI and “technology-enhanced” reviews that have been shown to spike denial rates.
It offers companies a cut of the “savings” they generate, creating a built-in incentive to say no.
It paves the way for more and more services to be put behind prior authorization walls.
And now, there’s a sign that her warning is resonating and that momentum is building against CMS’s latest experiment.
Last month, Representatives Alexandria Ocasio-Cortez Ocasio-Cortez (D-New York) and Lloyd Doggett (D-Texas) led 40 of their colleagues in a letter to CMS urging them not to start the model. The lawmakers wrote, “We are concerned that this effort could erode the quality of coverage provided by Traditional Medicare and result in the delay and denial of necessary health care,” and “Giving private for-profit actors a veto over care provided to seniors and people with disabilities in Traditional Medicare, even as a pilot program, opens the door to further erosion of our Medicare system. We therefore strongly urge you to immediately halt the proposed WISeR model and instead consider steps to address the well-documented waste, fraud, and abuse in the Medicare Advantage program.”
And just last week, a bloc of House members sent a letter to CMS Administrator Dr. Mehmet Oz urging the agency to cancel WISeR before it starts. The letter, led by Representative Suzan DelBene (D-Washington) and signed by 19 other members, pulls no punches: WISeR, they write, will “likely limit beneficiaries’ access to care, increase burden on our already overburdened health care workforce, and create perverse incentives to put profit over patients”.
The political significance of this is hard to overstate. The members of Congress who signed these letters have, in some cases, been reliable defenders of Medicare Advantage, an industry that now takes more than half of all Medicare dollars (plus billions in overpayments each year) while using prior authorization to deny necessary care at alarming rates. For them to publicly oppose a CMS initiative that so closely mirrors MA practices suggests something important: insurers may be losing some of their go-to allies on Capitol Hill.
And it’s not just the Dems.
The letters’ concerns echo those raised by Republicans in recent years, too. And that’s including some of Medicare Advantage’s biggest boosters. Representative Mark Greene, MD (R-Tennessee) led a bill with Representative Kim Schrier that would require physicians of the same specialty to review prior authorizations. And Senator Bill Cassidy (R-Louisiana), chair of the Senate Health, Education, Labor, and Pensions Committee stated that prior authorization is being “abused” by health insurance companies. The fact that opposition is now coming from both sides of the aisle demonstrates that this model may not be the antidote to prior authorization concerns that its proponents are touting it as.
Both letters reinforce those warnings, citing data from HHS’s Office of Inspector General showing that 75% of denied prior authorization requests in MA were overturned on appeal, which is proof that many initial denials were inappropriate. They also question why CMS would contract with the very companies (often MA insurers themselves) that have been caught breaking Medicare rules to boost profits.
For years, insurers have been able to rely on a bipartisan wall of protection for Medicare Advantage. With Democrats and Republicans saying “enough”, that could mean that the wall is starting to crack and it’s not just WISeR that’s in jeopardy. It’s the whole model of using private contractors to ration care in the name of “cost control.”
WISeR is scheduled to launch in January 2026 in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington. If CMS doesn’t reverse course, it will mark a turning point that Traditional Medicare began to look and feel like private Medicare Advantage plans.
But if the growing opposition is any sign, CMS may find itself pursuing other models to improve Traditional Medicare without using flawed methods from MA.
As a Family Doctor in practice for 39 years, I cared for many Medicare patients, and am now one myself. Medicare was a haven for people leaving the work force where they had managed care chosen by their employers. It was a relief for me as there is much less interference in the doctor-patient relationship in Traditional Medicare. I have watched as the for- profit Medicare Advantage plans have eaten up traditional Medicare members. These plans do NOT tell the truth that your choice of physicians and hospitals will be limited and that your doctor will have to get pre-authorization for tests and drugs that they know you need. Unearned Profit should have no place in medical care. I practiced evidence based care and followed specialty guidelines about what tests were indicated and what drugs were most cost effective. Prior authorization is just computerized rationing of care so CEOs of insurance companies can take home $20mil/year and health insurance industry has enough money to buy Congress. Medicare (dis)Advantage is just legal waste, fraud and abuse. It should be terminated not expanded.
I think you will reach more readers more effectively if you stop using so many acronyms - please spell out Medicare Advantage. the more people see and hear the words, the more recognition there will be.