A pilot programme that uses artificial intelligence to approve or deny certain Medicare services has produced the failures its critics predicted — and documents obtained by the Electronic Frontier Foundation now show how the incentives were built.
The programme, called WISeR (Wasteful and Inappropriate Service Reduction), began in January in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington. It requires prior authorisation for around a dozen services, including nerve stimulation, epidural steroid injections, cervical fusions, skin substitutes for wounds, and treatments for incontinence and impotence. It is scheduled to run until 2031.
The EFF documents describe a rushed rollout on technology that was not ready. One vendor, Innovaccer, asked the government to delay and, when it refused, temporarily configured its system to auto-approve every request to avoid a backlog. Another, Zyter, reportedly spent months confusing Medicare Part A with Part B. A third, Virtix, denied more than it approved: of 6,096 requests reviewed in one week in March, it approved 2,863 and denied 3,233 — 53 percent. WISeR promises decisions within 72 hours, but providers report waits of weeks and months; one request was still pending after 83 days. Virtix was placed on a corrective action plan for missing the window and says it has since cut its average turnaround to about 1.18 days.
In a Senate hearing, the CMS Office of the Actuary was quoted saying the model's participants 'will have an incentive to deny as many claims as possible' — CMS planning documents describe contractors being paid 25 percent of the regional benchmark cost of every service they avert. A quality score is meant to discourage bad denials, but a failing grade cuts that payment by only 10 percent. The Government Accountability Office already questioned the programme's legality in May. The administration plans to expand it to cancer treatment, advanced imaging, pacemakers and genetic tests.
