Trump Admin’s WISeR Pilot Targets ‘Waste’ with Prior Authorization—But at What Cost to Seniors?

As 2026 looms on the horizon, millions of Medicare beneficiaries in six states are bracing for a seismic shift in how their health coverage decisions are made.

Starting January 1, the Trump administration’s Centers for Medicare & Medicaid Services (CMS) will roll out the Wasteful and Inappropriate Service Reduction (WISeR) pilot program, deploying artificial intelligence to scrutinize and potentially deny coverage for certain procedures deemed “low-value” or prone to abuse.

This six-year experiment, running through 2031 in Arizona, Ohio, Oklahoma, New Jersey, Texas, and Washington, marks a bold foray into AI-driven prior authorization for traditional Medicare—a program that has long prided itself on minimal bureaucratic hurdles compared to its private counterparts.

But while proponents hail it as a tool to curb fraud and save taxpayer dollars—Medicare spent over $1 trillion in 2024 alone—critics warn it could erode trust, delay critical care, and echo the very insurance industry pitfalls the administration has publicly decried.

With CMS Administrator Dr. Mehmet Oz championing the initiative as a way to “crush fraud, waste, and abuse,” the WISeR pilot raises profound questions about balancing fiscal prudence with patient-centered care in an era of unchecked AI expansion.

The WISeR Blueprint: AI as Gatekeeper for Medicare Coverage

At its core, WISeR aims to test whether AI can streamline prior authorization—a process requiring pre-approval from insurers for specific treatments, tests, or prescriptions—to root out unnecessary services while expediting approvals for those that qualify.

Targeted procedures include skin and tissue substitutes for wound care, electrical nerve stimulator implants for pain management, and knee arthroscopies for osteoarthritis, all flagged as high-risk for overuse or fraud.

CMS has selected six tech vendors to administer the program regionally, leveraging AI algorithms to flag requests against evidence-based guidelines, with final decisions resting on human clinicians.

Exemptions are built in for inpatient services, emergencies, or treatments where delays could pose “substantial risk,” and CMS insists no denial will occur without a qualified reviewer’s sign-off.

Vendors will share in “savings” from averted procedures, but CMS spokesperson Alexx Pons emphasizes prohibitions on denial-tied incentives, framing WISeR as a “streamlined” evolution of existing Medicare safeguards.

Oz, in announcing the pilot on June 27, 2025, touted it as bringing Medicare “into the 21st century” by combining tech speed with clinical oversight.

This isn’t uncharted territory for health care; private insurers have long used AI for claims processing. But traditional Medicare’s limited use of prior authorization—confined mostly to durable medical equipment—has shielded its 33 million enrollees from the delays plaguing Medicare Advantage plans, where 99% impose such requirements.

WISeR’s expansion could affect up to 10 million beneficiaries in the pilot states, potentially adding layers of red tape to a program designed for accessibility.

A Tale of Two Policies: Cracking Down on Private Insurers While Importing Their Tactics

The WISeR launch, just days after a June 23, 2025, voluntary industry pledge to reform prior authorization, has fueled accusations of hypocrisy.

In that earlier initiative, spearheaded by HHS Secretary Robert F. Kennedy Jr. and Oz, 11 major insurers—including UnitedHealthcare, Aetna, and Humana—committed to reducing PA volumes by 2026, standardizing electronic submissions, and achieving 80% real-time decisions by 2027.

Covering 80% of Americans, the pledge was hailed as a patient-first response to “violence in the streets” over insurance frustrations, like the December 2024 shooting of UnitedHealthcare CEO Brian Thompson.

Oz himself lambasted PA as eroding trust and causing “significant delays,” vowing the administration wouldn’t tolerate it. Yet WISeR imports the very tool into Medicare, prompting bipartisan backlash.

Washington Democrat Rep. Suzan DelBene called it “talking out of both sides of their mouth,” while Ohio State University’s Dr. Vinay Rathi labeled the mixed signals “hugely concerning.” Even Republican Rep. Greg Murphy, a urologist, decried insurers’ “damnedest to deny” care, echoing boardroom profit motives now mirrored in federal policy.

Pons defends the duality: Both aim to “protect patients and Medicare dollars.” But with Medicare’s $1 trillion+ spend dwarfing private plans, the stakes are higher—fraud alone cost $60 billion in 2024, per CMS estimates.

The Human Toll: Delays, Denials, and a Public Fed Up with Bureaucracy

Prior authorization’s reputation precedes it: A July 2025 KFF poll found 73% of adults view insurer delays and denials as a “major problem,” with 51% personally encountering issues in the prior two years.

For Medicare seniors—many with chronic conditions—these hurdles aren’t abstract. Delays can cascade into emergency visits, hospitalizations, or abandoned treatments, with 94% of physicians reporting PA burdens patient care.

A February 2025 AMA survey amplified alarms: 61% of physicians fear AI will spike denials, overriding judgment and worsening harms, while 89% link PA to burnout. One in three doctors face frequent denials, often for evidence-lacking criteria, forcing out-of-pocket payments or appeals that succeed 80% of the time—yet only 20% bother due to resource drains.

ProPublica’s 2023 exposé on Cigna’s PXDX algorithm—denying 300,000 claims in two months at 1.2 seconds each—illustrates the peril: Bulk rejections without file reviews, later overturned en masse on appeal.

Class actions against UnitedHealth and Cigna allege AI ignores nuances, saddling patients with bills for “medically necessary” care. WISeR’s shared-savings model—rewarding vendors for cost cuts—could amplify these biases, per the Washington State Hospital Association’s Jennifer Brackeen.

AI’s Double-Edged Sword: Promise vs. Peril in Health Care Gatekeeping

AI’s allure is efficiency: Insurers claim it slashes errors, biases, and delays, potentially saving billions—Medicare overpays $84 billion annually on Medicare Advantage alone, per MedPAC.

Theoretically, WISeR could expedite “expedited” reviews, aligning with the industry’s 2027 real-time goal. CMS vows “strict oversight” for transparency and patient safeguards, prohibiting denial-linked pay.

Yet experts like Georgetown’s Amy Killelea question “meaningful human review,” citing Cigna’s 1.2-second sham scrutiny. Rathi’s “messy and subjective” metrics rely on self-assessing contractors, risking skewed outcomes.

A Senate probe found AI denial rates 16 times human norms, often batching without context. In fragmented Medicare—serving vulnerable elders—such opacity could exacerbate disparities, with higher utilizers (e.g., chronic illness patients) hit hardest.

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WISeR fits Trump’s fiscal hawkery, targeting $60 billion in annual fraud. But amid rising Part B premiums ($206.50 in 2026, up $21.50), it risks alienating a key voting bloc—73% already decry PA as “major.” Bipartisan bills like the Improving Seniors’ Timely Access Act seek reforms, but WISeR’s vendor model invites profit-driven abuse akin to Medicare Advantage overpayments.

As WISeR launches, calls for robust monitoring grow. The AMA demands AI as “augment,” not arbiter, while Democrats like DelBene push bills to halt it. Patients in pilot states should track requests via CMS portals and appeal aggressively—success rates hover at 80%. For the rest, this pilot could foreshadow national AI integration, amplifying the need for evidence-based guardrails.

In a system where trust hangs by a thread, WISeR’s success hinges on proving AI serves patients, not just spreadsheets. As Oz put it, Medicare must evolve—but not at the expense of those it protects. The algorithm is watching; so should we.