CMS Barrels Ahead With WISeR, Providers and Seniors Left in the Dark

Ready or not, denial algorithms are coming to traditional Medicare.

The new year will bring new hurdles for doctors and patients thanks to the Centers for Medicare & Medicaid Services (CMS)’s Wasteful and Inappropriate Service Reduction (WISeR) Model set to launch on January 1, 2026. The program will, for the first time in traditional Medicare’s 60-year history, outsources critical coverage decisions to private, for-profit contractors using artificial intelligence-enabled prior authorization (PA).

As Rachel Madley, PhD and I wrote last month, WISeR is no minor administrative tweak. The model hands enormous control to six private companies (many financed by insurers or venture capital arms tied to them) empowering these firms to decide whether seniors get 17 different medical services that have never required PA in the history of traditional Medicare. Even more troubling: several of these companies already operate inside Medicare Advantage, where PA has become synonymous with denials, delays and life-altering barriers to care.

This week, I tuned in to CMS’s one-hour webinar for providers about the WISeR rollout. If this is CMS’s big effort to prepare the medical community for a historic change, all I can say is: providers deserve better. The webinar was light on details and raised more questions than answers.

At its core, the program fails the most basic criteria for how to design and implement programs to improve health care quality. The Institute for Healthcare Improvement (IHI), the world’s preeminent organization in this arena, consistently emphasizes four key pillars:

Let’s see how WISeR stacks up.

1. Engaged physician leadership

   As someone who has led large scale transformation initiatives in partnership with the CMS Innovation Center (including serving as the founding president for the one of the country’s largest and most successful Next Generation ACOs), this is foundational. Yet in this model physicians are an afterthought.

   Even worse, physicians feel like sand is being thrown in their eyes. On the webinar, CMS revealed they prioritized vendors based on their “success” in Medicare Advantage prior authorization.

   That is, clearly, notable.

   Medicare Advantage’s (MA) PA practices have been under fire from federal watchdogs, physicians and patient advocates for years because PA routinely delays or denies medically necessary care. “Success” in that context means reducing utilization — not improving outcomes for seniors.

   Rewarding that track record and importing it directly into traditional Medicare should give every provider, patient, and policymaker pause.

2. Aligned incentives & payment models.

   One of the biggest fears about WISeR is that it will recreate Medicare Advantage’s financial incentives: vendors earn more by denying more care. CMS refutes this, saying model participants are not incented to deny care despite explicitly tying incentive payments to vendors to reductions in approved services. While CMS tried to reassure providers that their oversight will prevent abuse it does not resolve the fundamental contradiction between the stated goal (“no incentive to deny care”) and the operational mechanics of the payment model (the details of which have not been disclosed). It also ignores the sophistication and track record of for-profit companies (now armed with AI) to game the system to their advantage.

   And provider incentives for making improvements in care are completely absent for the first time in the history of CMMI.

3. Care models that support clinicians

   CMS is relying heavily on WISeR vendors — many of whom have limited experience with physician practices — to educate the provider community and provide at-elbow support. That alone is a major red flag. Providers who expressed concerns that they have yet to hear from the vendors were told by CMS that the “participants” are gathering information and is “forthcoming”. Hardly reassuring given CMS is barreling toward a 1/1/26 start date which will entail enormous changes in provider workflows.

   

   The messaging is also incredibly confusing. CMS has repeatedly said that providers aren’t participants in the model. Vendors are.

   And that distinction is huge: if a provider doesn’t submit PA, every claim for the affected procedures becomes subject to new prepayment review — virtually guaranteeing surprise denials and delays (and shifting more financial risk to patients). So let’s call a spade a spade, WISeR is NOT optional for providers, and they need to know that.

4. Timely, actionable data and transparency

   No baseline data about cost, utilization (including PA submissions and denials), or variation in provider use of the targeted procedures has been disclosed. This is in stark contrast to prior CMMI models, where providers receive data well in advance so they can understand their baseline performance and plan accordingly.

   And what about the development and use of measures to assess the impact of this program on patient quality and provider experience? CMS said that it is “exploring the potential inclusion” of such measures. Never before has CMS introduced a new payment model so thin on quality and safety measurement.

The big rush

CMS is rushing to implement a model that empowers private vendors, many already with deep ties to Big Insurance, to gatekeep care for millions of seniors. And if the agency’s own webinar is any indication, they have not fully reckoned with the confusion, denials and disruption that providers and patients will face when CMS’s Medicare Advantage-ification of traditional Medicare kicks into full swing on New Years Day.

Seth Glickman, MD, is a former insurance and health system senior executive. He now is a researcher and advocate for reform in the health care finance space.