Lawmakers Seek to Halt Medicare’s AI-Assisted Prior Authorization Model

The House of Representatives Appropriations Committee has approved legislation that, if passed, would bar Health and Human Services federal funding from being used to implement any model that implements prior authorization in traditional Medicare, including the Wasteful and Inappropriate Service Reduction (WISeR) Model, which relies on artificial intelligence (AI).

ASNC was among 35 physician organizations that went on record opposing the model in 2025. Of particular concern is the model’s payment structure, which would reward vendors for authorization denials. ASNC is concerned that advanced diagnostic imaging could be targeted in future years and has been advocating aggressively to curtail payer use of prior authorization, not expand it to fee-for-service Medicare.

Background on WISeR

The WISeR Model was launched early this year in 6 states (Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington) through which the Centers for Medicare & Medicaid Services (CMS) contracts with third parties to use AI to review authorization requests for services that CMS says are vulnerable to fraud, waste, and abuse. The services initially targeted by the model are skin and tissue substitutes, electrical nerve stimulator implants, and arthroscopy for knee osteoarthritis.

Physicians and suppliers in the model states are not required to submit requests for prior authorization for the targeted services; however, their claims are subject to medical review to ensure the delivered service met Medicare coverage, coding, and payment criteria prior to payment. Stay tuned for updates on this evolving advocacy issue.

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