Medicare’s WISeR Pilot Pays Vendors to Stop Care

Medicare’s WISeR prior authorization pilot paid private vendors to stop claims in six states, then launched after a contractor said the software was not ready. The Wasteful and Inappropriate Service Reduction model went live on January 1, 2026, for original Medicare, not Medicare Advantage.

The portal bugs are real. The lasting change is the design: commercial-style pre-approval, run by tech firms that collect a cut of spending they stop, through December 31, 2031.

Commercial Prior Authorization Comes to Original Medicare

The Centers for Medicare and Medicaid Services calls WISeR a six-year test in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington. About 6.4 million people on original Medicare in those states sit inside the test, using enrollment figures the Congressional Research Service drew from CMS data for August 2025.

CMS says the model does not change coverage rules or what doctors are paid when a service is allowed. It does add a new gate. Clinics must seek prior authorization for a selected set of outpatient items, or skip that step and face a pre-payment review before Medicare pays.

That is a break with how original Medicare has worked. CRS calls WISeR one of the largest expansions of prior authorization in traditional Medicare. In fiscal 2023, existing original-Medicare prior auth programs reviewed 3.1 million claims, less than 1 percent of 1.2 billion Part A and Part B claims. Medicare Advantage is already built on this machinery: nearly all of those enrollees are in plans that require prior auth for some services, at about 1.8 determinations per person in 2023 versus 0.01 in traditional Medicare.

CMS wrote the goal in plain language. It wants to “apply commercial payer processes that may be faster, easier and more accurate.” The agency also says WISeR is the first Innovation Center model in which technology companies are the only participants, and that the test “can provide a roadmap for incorporating more private sector innovations into CMS operations.” Clinics and patients in the six states cannot opt out. The “voluntary” label applies to the vendors that applied, not to the people whose care now waits on those vendors.

Vendors Collect 25 Percent of Averted Spending

The six contractors are not paid a flat fee to run a help desk. CMS’s participant guide sets the WISeR payment rate at 25 percent of a regional benchmark, or of averted spending, for a qualifying denial, after a discount and a quality adjustment. The public methodology document says participants may earn a share of the savings attributable to prior authorization and pre-payment review.

A denial only pays if the request fails existing Medicare coverage rules, is unique, and is not later reversed on resubmission or appeal. CMS can recoup the vendor’s fee if an appeal succeeds. Every non-affirmation, CMS’s word for a denial, must be signed off by a licensed clinician. Vendors also eat the cost of unlimited resubmissions and get only one payment per enrollee for a given service.

HOW THE DENIAL FEE IS SUPPOSED TO WORK

• The trigger: Payment is tied to a stopped claim, not to an approval.
• The rate: CMS sets the starting share at 25 percent of a regional benchmark or of averted spending, then applies a discount and a quality score.
• The clinician: A licensed reviewer has to confirm that a denial matches Medicare coverage criteria.
• The clawback: If a provider wins an appeal, CMS withholds or recoups the vendor’s payment.

Those rules look stricter on paper than the proprietary screens Medicare Advantage plans have used for years. They do not change the basic math. A vendor still makes money when care does not go through, which is why the unfinished launch is not only an IT story.

An 83-Day Wait and an Unfinished Portal

CMS announced WISeR on June 22, 2025, posted a request for applications five days later, and set a July 25, 2025 deadline. The model launched about six months after that announcement. Requests opened January 5, 2026, for dates of service on or after January 15, 2026.

The Electronic Frontier Foundation sued in March 2026 after a January 29 Freedom of Information Act request, then released about 1,000 pages of contracts, status reports, and clinic complaints in September 2026. About a month before launch, Innovaccer, the Ohio vendor, told CMS it would go live with software that lacked full functions and had not been fully tested. It cited changing requirements, unclear governance, and no time for end-to-end testing with clinics.

CMS tells vendors to answer prior authorization requests within 72 hours. Internal status reports from the first months show many files took far longer. One request was still unanswered at 83 days. Several hundred were still open at the end of March 2026. Status notes also describe system downtime, mixed-up request categories, and broken handoffs between vendors and Medicare Administrative Contractors.

WISER’S FIRST NINE MONTHS

1. June 22, 2025: CMS announces the model under Innovation Center authority, which CRS says was used to waive statutory limits on prior authorization in Medicare.
2. July 25, 2025: Vendor applications are due, 28 days after the June 27 request for applications.
3. December 2025: Innovaccer warns CMS it will launch without full functions.
4. January 1, 2026: WISeR starts in the six states.
5. March 25, 2026: EFF files its FOIA lawsuit.
6. March 30, 2026: A status report logs the 83-day wait and early denial totals.
7. August 14, 2026: Virtix says its corrective action plan closed.
8. September 2026: EFF publishes the roughly 1,000-page file.

EARLY OPERATING MARKS

• Decision clock: CMS’s public standard is 72 hours.
• Longest cited wait: 83 days for one unanswered request.
• Early denials: Two companies denied 5,944 prior authorization requests in the first three months.
• End date: The test is scheduled through December 31, 2031.

Lena Cohen, a staff technologist at EFF, said CMS already knew the pattern.

There’s alarmingly high denial rates, and that is known by CMS. A significant number are not getting responses within three days [as required]. Many are waiting over a month to receive a reply, and that’s really concerning.

Lena Cohen, staff technologist, Electronic Frontier Foundation

CMS said it “closely monitors the implementation of all models, including system performance and denial patterns, and is actively addressing issues as they arise.”

Which Procedures Need Approval in the Six States

WISeR applies to a CMS-chosen list of outpatient services the agency calls low-value or vulnerable to waste, not to hospital admissions or emergency care. In the six states, that list includes skin and tissue substitutes, epidural steroid injections for pain, knee arthroscopy for osteoarthritis, cervical fusion, several nerve stimulators, incontinence devices, and treatments for impotence. Deep brain stimulation was held back from the January 1, 2026 start and left for a later year.

Each state has one vendor, paired with a Medicare Administrative Contractor. Providers can file the request with the vendor or through the contractor, which forwards it. Skip the request, and the claim is parked for pre-payment review. An affirmed request gets a tracking number that travels with the claim. CMS has also said clinics with a clean record may later earn a “gold card” exemption so reviewers can spend time on higher-risk files.

WISER VENDORS BY STATE

The list is the point of the experiment. These are the same kinds of procedures commercial plans already stall, including pain shots, wound products, and devices. Put that screen inside original Medicare, pay the screener a share of stopped spending, and the six states become the place CMS learns whether that import holds.

Patient Harm Reports in the Ohio Feedback File

The FOIA set includes March 2026 replies to a feedback form about Innovaccer, which handles Ohio. Clinics described delayed surgeries, poor communication, and patients left waiting. One form, written in capital letters, said a clinician had watched three patients cry at the bedside after no word on prior auth for kyphoplasty, a vertebral augmentation used for compression fractures, and added that the patients were in deep pain.

In Washington, CMS put Virtix Health on a corrective action plan after audits on clinical determinations, communications, portal function, customer service, and speed. Virtix was missing the 72-hour clock. The company said the plan was imposed for turnaround times in the first quarter, that times later fell inside the window, and that the plan closed on August 14, 2026. CMS said that after the corrective steps, Virtix’s times improved and were “on track to meet the model’s three-day requirement.” An earlier agency note said prior auth turnaround had been about five days for the first four months, then improved to 1.7 days for prior auth and just over three days for pre-payment review.

Two companies alone denied 5,944 prior authorization requests in the first three months. Virtix denied more requests than it approved in that stretch. Miranda Yaver, a health policy researcher who has tracked the model, called it “a really big change to traditional Medicare” and said “the report card is pretty unimpressive.”

David Lipschutz, co-director of the Center for Medicare Advocacy, had warned before launch that paying vendors a share of blocked care deputizes them as a “whole new bounty hunter.” By June 2026 he was saying the pilot was not going smoothly anywhere and could import some of the worst parts of Medicare Advantage into the program that had mostly avoided them.

How Lawmakers Tried to Stop the Pilot

Rep. Greg Landsman, a Democrat from Ohio, introduced the Ban AI Denials in Medicare Act on December 2, 2025. The bill would bar the secretary of Health and Human Services from testing WISeR or any similar model, and would block Innovation Center models that add prior authorization, including through artificial intelligence, to original Medicare Parts A and B.

On May 20, 2026, Landsman and Rep. Suzan DelBene of Washington introduced a Congressional Review Act resolution after the Government Accountability Office found that the WISeR notice is a rule Congress can disapprove. DelBene said the program “implements the same flawed prior authorization scheme from Medicare Advantage into traditional Medicare” and, if scaled, would be “a back door to privatizing Medicare.” A Senate effort to roll the model back failed in July 2026.

The model is still active. CMS can add or drop services, audit vendors, demand corrective plans, and terminate a participant for bad performance. It has not taken the gate down. Coverage criteria stay the same on paper. The new fact is who stands in front of the claim, how that firm is paid, and how long a person in pain waits while the file moves.

WISeR’s own site still sells the test as a roadmap for more private tools inside CMS. The six states are already on that map, and the calendar runs to December 31, 2031.

Disclaimer: This article is news reporting on a federal Medicare model and related public records. It is for information only and is not medical, legal, or insurance advice. It does not tell any reader whether to seek, delay, or appeal a specific procedure, and it does not interpret an individual Medicare determination. People who have a claim in one of the six WISeR states should talk with their clinician and, if needed, a qualified elder-law attorney or Medicare counselor before acting on a denial or a delay. Figures and program rules reflect the CMS documents, congressional materials, and FOIA records cited here and can change as the model continues.