You’ve probably seen the headlines by now: Centers for Medicare and Medicare Services (CMS) is getting ready to test prior authorization for procedures for people on original Medicare living in certain states. This new prior authorization pilot is called “WISeR” and they’re planning to use Artificial Intelligence (Ai) as the first line of defense to determine who gets approved for treatment for certain conditions. The idea sounds reasonable enough on the surface—cut down on waste and stop unnecessary treatments. But here’s the thing: this could end up changing the best parts of Medicare while still retaining the worst!
Medicare is far from perfect. Enrolling in Medicare can often be a headache navigating confusing deadlines, draconian penalties, and the alphabet soup of Plans and Parts. The seemingly arbitrary rules for when you can enroll or switch Medicare insurance coverage needs to change.
But once you’re enrolled in Original Medicare, however, you can take solace in the fact that you can see nearly any doctor in the United States without referrals. Over 98% of non-pediatric doctors accept Medicare (source) which makes finding a doctor easy compared to confusing insurance company doctor networks. In fact, insurance companies are currently not involved in any U.S. based health decisions when you have Original Medicare (with or without a supplemental Medigap plan). Prior authorizations are extremely rare in Medicare and we believe this cuts down on bureaucracy and lets doctors and patients focus on health outcomes rather than red tape. Doctor and patient support is the core promise of Medicare.
WISeR is an acronym for “Wasteful and Inappropriate Service Reduction” and the pilot will take place in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington State starting Jan 1, 2026. This could end up creating the exact same headaches that make Medicare Advantage so frustrating for patients. We talk to older adults every single day, and so many of them tell us they want to avoid the delays and denials that come with Medicare Advantage’s prior authorization hoops. Now it feels like someone’s moving the goalposts on them, changing the rules for people who thought they were signing up for something straightforward and dependable.
And then there’s the Ai piece, which honestly makes us nervous. Sure, these systems can scan through paperwork quickly, but they don’t get the full picture of what’s going on with each patient. They can’t read between the lines or understand when someone’s health situation is more complicated than it looks on paper. CMS says human doctors will make the final calls, but we’ve seen how this plays out with Medicare Advantage. Too often, that “human review” just becomes someone rubber-stamping what the computer already decided. It’s pretty clear what could happen: more treatment delays, more denials, and a lot of people who don’t have the energy or resources to fight back.
Look, we get it—nobody wants to see Medicare dollars wasted. But Ai-powered prior authorization isn’t the answer. Medicare was supposed to be the simple option, the one that doesn’t make you jump through hoops to get the care you need. Before CMS starts importing all the worst parts of private insurance into traditional Medicare, maybe they should actually listen to the people who depend on it most-Seniors.
And we are not alone with our concern. The American Medical Association put out the following statement “The AMA strongly urges CMS to pause the January 1, 2026 implementation of the WISeR Model to allow additional stakeholder input, full analysis of the model’s operational impacts, and development of clear guidance for physicians.” (source)
If WISeR concerns you, reach out to your elected officials to demand common sense Medicare reforms like simplifying enrollment rules but place a hold on these new Ai authorizations.