Dive Brief:
- Senate Democrats’ bid to end a pilot program that adds artificial intelligence-backed prior authorization for some services in Medicare failed on Thursday.
- The Senate voted 46-50 along party lines to preserve the WISeR model, a controversial experiment launched by the Trump administration early this year that adds prior authorization to some in Medicare services in six states.
- The pilot program has received a wave of criticism from patient advocates, providers and lawmakers — particularly Democrats — who say WISeR is delaying seniors’ care and creating more administrative work for clinicians.
Dive Insight:
The Wasteful and Inappropriate Service Reduction model is a mandatory experiment launched in six states this year by the CMS’ innovation center in a bid to cull wasteful spending in Medicare.
Under the pilot, the federal government contracts with private companies to add prior authorizations for certain services deemed vulnerable to abuse and wasteful spending, like skin and tissue substitutes or epidural steroid injections for pain management.
WISeR is a departure from the norm in Medicare, which largely doesn’t require pre-approvals for services. Democrats have pushed back on the pilot for months, raising concerns that WISeR would limit Medicare beneficiaries’ access to care.
“Seniors paid into Medicare out of every paycheck during their working years, and they did so with an expectation they would have an ironclad guarantee of affordable healthcare,” Sen. Ron Wyden, D-Ore., said on the Senate floor Thursday. “Today, seniors in six states across America are discovering that care their doctor has recommended for them has been slowed or halted by a shadowy, AI-driven third party.”
A group of Democrat senators, including Wyden, Maria Cantwell, D-Wash., Richard Blumenthal, D-Conn., and Kirsten Gillibrand, D-N.Y., had introduced a resolution that would invoke the Congressional Review Act — a legislative tool lawmakers can use to overturn agency actions — to end the pilot.
But Republicans blocked the measure this week. During arguments before the vote, Sen. Mike Crapo, R-Idaho, argued Medicare’s reimbursement structure rewards providing a high volume of services, rather than high-value care — and that WISeR could help tamp down wasteful and fraudulent spending.
“Every member of this body agrees that patients should have access to high-quality care, providers deserve predictable payment for services, and avoidable waste, fraud and abuse in Medicare should be stopped,” he said. “Ending this pilot program prematurely will deprive CMS of a useful tool to accomplish each of those goals.”
Congress may have other opportunities to review WISeR. Last month, a House panel unanimously voted to add an amendment to HHS’ 2027 spending bill that would block funds from being used to implement the model.
