Aug. 5, 2025
We, the undersigned organizations and individuals, issue the following consensus statement regarding the Wasteful and Inappropriate Services Reduction (WISeR) model recently proposed by the Center for Medicare and Medicaid Innovation to begin January 1, 2026.
Background
The WISeR model proposes to implement prior authorization for at least 17 additional services in traditional Medicare (TM) in six states. The model will solicit applications from private companies that currently administer prior authorizations for private health insurers, including Medicare Advantage (MA) plans. The model will run for 6 years.
Shared Perspective
As former government officials, providers, policy experts, researchers, and patients, we are concerned about the design of the model and recommend it not be initiated. Our specific concerns are outlined below.
1. Participant payment model: The WISeR model proposes to compensate the private companies participating “based on a share of averted expenditures.” This payment structure immediately creates an incentive for companies to avert more expenditures by denying more prior authorization requests in order to increase their compensation. Evidence from government agencies and experts across the political spectrum has demonstrated that MA prior authorization, which also results in additional retained revenue when care is denied, very often improperly denies care. (1,2) A participant payment model that mirrors the current incentives in MA is likely to fall victim to the same misaligned incentives and lead to delays and denials of needed care.
2. Participant selection: The model intends to allow participants who are currently administering prior authorization processes for private payers, including MA companies. Currently, the Medicare Administrative Contractors (MACs) that administer prior authorizations in TM have an accuracy rate of over 98%. (3) Further, MAC prior authorization decisions are overturned less than half as frequently (roughly 35%) as decisions made by private companies administering MA prior authorization with an 81.7% overturn rate. (4) Thus, the participants desired for the WISeR model have demonstrated inferior performance in making accurate prior authorization decisions, which have resulted in serious harm and death to patients. (5) These same bad actors should not be given the ability to make these decisions in TM.
3. Prior authorization protocols: The lack of transparency in MA prior authorization makes it impossible to justify expanding these processes into TM, based on evidence of their accuracy or benefit to patients and providers. MA insurers do not report prior authorization decisions based on type of service, contract, or reason for denial. Additionally, the protocols used to review prior authorizations in MA are not disclosed to patients, providers, or policymakers. Given that prior authorization in MA is a black box with documented adverse effects on patients and moral injury to providers, expanding the process without a full public audit of how it is currently conducted with recommendations for improvement is risky. (6)
4. Use of enhanced technology: The model references the use of enhanced technologies for prior authorization review. However, these technologies, particularly the use of artificial intelligence (AI) systems, have been associated with significantly higher rates of care denials. For instance, internal documents from MA insurers demonstrate that denials for post-acute care services rose sharply following the implementation of AI-driven review processes administered by naviHealth, a subsidiary of UnitedHealth Group. (7) Often these denials in MA are inappropriate as the Department of Health and Human Services Office of the Inspector General and whistleblowers have demonstrated. (8,9) This, combined with the lack of transparency into the methodologies behind the enhanced technologies used by private insurers (the intended model participants) could result in delays and denials of needed care for seniors and people with disabilities enrolled in TM.
Signed,
Center for Health and Democracy
Physicians for a National Health Program
Public Citizen
Center for Medicare Advocacy
Robert Berenson, MD, Former Commissioner of the Medicare Payment Advisory Commission
Donald Berwick, MD, Former Administrator, CMS
Andrea Ducas, MPH, Vice President for Health Policy, Center for American Progress
Clifton Gaus, ScD, Former Administrator of Agency for Health Care Policy and Research (now AHQR)
Richard Gilfillan, MD, Former Director, Center for Medicare and Medicaid Innovation
Ed Weisbart, MD, National Board Secretary, Physicians for a National Health Program
Bruce C. Vladeck, Administrator, Health Care Financing Administration, 1993-1997, Board Chair Emeritus, Medicare Rights Center
Judy Feder, Professor and former Dean, McCourt School of Public Policy, Georgetown University
This statement was sent to the U.S. Department of Health and Human Services, the Centers for Medicare and Medicaid Services, and the Congressional staff members on Aug. 5, 2025.
References
- U.S. Department of Health and Human Services, Office of Inspector General, Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care, report no. OEI-09-18-00260, April 2022, https://oig.hhs.gov/reports/all/2022/some-medicare-advantage-organization-denials-of-prior-authorization-requests-raise-concerns-about-beneficiary-access-to-medically-necessary-care/.
- Jeannie Fuglesten Biniek, Nolan Sroczynski, Meredith Freed, and Tricia Neuman, “Medicare Advantage Insurers Made Nearly 50 Million Prior Authorization Determinations in 2023,” KFF (January 28, 2025), https://www.kff.org/medicare/issue-brief/nearly-50-million-prior-authorization-requests-were-sent-to-medicare-advantage-insurers-in-2023/.
- U.S. Centers for Medicare & Medicaid Services, Prior Authorization and Pre‑Claim Review Program Statistics for Fiscal Year 2023, January 17, 2025, https://www.cms.gov/files/document/pre-claim-review-program-statistics-document-fy-23.pdf
- Jeannie Fuglesten Biniek, Nolan Sroczynski, Meredith Freed, and Tricia Neuman, “Medicare Advantage Insurers Made Nearly 50 Million Prior Authorization Determinations in 2023,” KFF (January 28, 2025), https://www.kff.org/medicare/issue-brief/nearly-50-million-prior-authorization-requests-were-sent-to-medicare-advantage-insurers-in-2023/.
- Jennifer Lubell, When Prior Authorization Blocks Lifesaving Treatments, American Medical Association (April 7, 2025), https://www.ama-assn.org/practice-management/prior-authorization/when-prior-authorization-blocks-lifesaving-treatments.
- U.S. American Medical Association, 2024 AMA Prior Authorization (PA) Physician Survey (American Medical Association, 2024), https://www.ama-assn.org/system/files/prior-authorization-survey.pdf
- U.S. Senate Permanent Subcommittee on Investigations, Refusal of Recovery: How Medicare Advantage Insurers Have Denied Patients Access to Post‑Acute Care, Majority Staff Report (October 17, 2024), https://www.hsgac.senate.gov/wp-content/uploads/2024.10.17-PSI-Majority-Staff-Report-on-Medicare-Advantage.pdf
- U.S. Department of Health and Human Services, Office of Inspector General, Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care, OEI‑09‑18‑00260 (April 2022), https://oig.hhs.gov/reports/all/2022/some-medicare-advantage-organization-denials-of-prior-authorization-requests-raise-concerns-about-beneficiary-access-to-medically-necessary-care/.
- Casey Ross and Bob Herman, “UnitedHealth Pushed Employees to Follow an Algorithm to Cut Off Medicare Patients’ Rehab Care,” STAT (November 14, 2023), https://www.statnews.com/2023/11/14/unitedhealth-algorithm-medicare-advantage-investigation/.