The program is called WISeR. It stands for Wasteful and Inappropriate Service Reduction. Since January it has been using artificial intelligence to say yes or no to the care that doctors have ordered for people on Medicare.
Medicare never worked that way before. The people on it are old, and their doctors did not have to ask permission first. Now, in six states—New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington—they do. The pilot requires prior authorization for about a dozen services: nerve stimulation, steroid injections into the spine for pain, fusions of the bones in the neck, skin substitutes for wounds, treatments for incontinence and impotence. It is set to run until the end of 2031. The stated purpose is “appropriate Medicare payment” and savings for the taxpayer through less fraud, waste and abuse.
What followed was not orderly. There were technical failures. There were decisions that took weeks. There were denials no one could explain and vendors no one could reach. Much of it is now in writing. The Electronic Frontier Foundation, fighting the government in litigation, obtained federal records about WISeR and released them this month. The records carry the voices of the providers. One called the program “a disgrace to the human race” and reported watching patients cry in pain while they waited.
One Ohio provider, in a survey response written in all capital letters, described patients waiting for approval of a minimally invasive surgery for compression fractures of the spine:
I HAVE HAD TO WATCH 3 PATIENTS CRY AT BEDSIDE FOR NOT HEARING BACK ON THEIR PRIOR AUTH FOR KYPHOPLASTY/VERTABRAL AUGMENTIATION PROCEDURE. THESE PATIENTS ARE IN DEEP PAIN. SO MANY OFFICES OF MY PHYSICIANS ARE NOT HEARING BACK FROM INNOVACCER… THERE IS NO WAY TO GET A HOLD OF A HUMAN TO TALK TO… WHAT A DISGRACE TO THE HUMAN RACE IN AMERICA. THIS IS THIRD WORLD.
Innovaccer, the vendor that provider saw, was not ready when the rollout came. It asked the government to delay. The government did not delay. So the company set its machine to approve every request, for a time. “[A]uto-affirming is the only path available that avoids creating a backlog of unprocessed prior authorizations and claims while we finalize, validate, and deploy the full rules-based solution,” Innovaccer wrote in a letter to federal officials.
Another vendor, Zyter, carried bad data for months. The records suggest the company had not grasped the difference between Medicare Part A, which covers hospital care, and Part B, which covers outpatient services. Zyter’s chief executive, Sundar Subramanian, told Ars Technica in a written statement that the company is now “fully functional across Medicare Part A and Part B claims” and is working with federal partners and healthcare providers to “enhance the experience.”
A third vendor, Virtix, was refusing more requests than it granted. Its own weekly report for March 30 shows 6,096 prior-authorization requests reviewed and 2,863 approved. It denied 3,233. That is 53 percent.
The program promises answers within 72 hours. Many answers took weeks. Some took months. The released records show at least one request still pending after 83 days. In a survey, one provider said it “had a surgery pushed back almost two months due to zero communication.”
Ars Technica reported that in June the Centers for Medicare and Medicaid Services placed Virtix under a Corrective Action Plan for “noncompliance” with the 72-hour window. Virtix confirmed the plan and said it has since “reduced its average turnaround time for prior authorization to 1.18 days and prepayment review determinations to 1.17 days.” The plan ended on August 14, the company said. Virtix also said it does not take lightly “the impact that the prior authorization process can have on people who are in pain and seeking relief,” and that it applies coverage rules set by the government, not its own. Whether any other vendor was put under such a plan is unknown. CMS and the Department of Health and Human Services did not answer Ars Technica’s questions.
Last week, in a Senate hearing, Sen. Patty Murray put the question of money to Chris Klomp, the deputy administrator of CMS and President Trump’s nominee for deputy secretary of Health and Human Services. “Do the contractors in the model—who are the private companies conducting the prior authorization assessments—make more money if they deny care? Just ‘yes’ or ‘no,’” Murray asked. “My understanding is no,” Klomp replied.
Also last week, Rep. Suzan DelBene called a committee vote seeking the release of more WISeR documents. Republicans voted the effort down. “It’s clear why the administration is doing everything they can to conceal these documents,” DelBene said. “The more that Americans learn about WISeR, the more outraged they get at the Trump administration for jeopardizing their care and trying to privatize Medicare.”
In May the Government Accountability Office found that the officials who set up the program did not follow the proper procedure, putting its legality in question. The program goes on anyway. The plan is to expand it in the years ahead.
Innovaccer did not answer Ars Technica’s request for comment. It told Stat News its technology is now “fully live” and that it has “worked closely with all of our partners to refine and improve the program since its launch and we will continue to do so with the spirit of putting patients first.”
A second Ohio provider, in one of the released surveys, called the delays and the silence “extremely disappointing” and wrote: “Programs affecting patient access to medically necessary procedures must have reliable provider support systems. Currently, that standard is not being met. Patients deserve better. Providers deserve answers. And systems designed to improve care should never result in preventable suffering.”