Press Releases

Today, Representatives Suzan DelBene (WA-01), Ami Bera, MD (CA-06), Llyod Doggett (TX-35), Greg Landsman (OH-01), Rick Larsen (WA-02), Alexandria Ocasio-Cortez (NY-14), and Kim Schrier, MD (WA-08) led a letter along with 28 of their colleagues urging leadership of the House Appropriations Committee to repeal the Centers for Medicare and Medicaid Services’ (CMS) Wasteful and Inappropriate Service Reduction (WISeR) Model, or any related prior authorization model, from traditional Medicare in the upcoming federal funding process.

Starting this January, CMS began implementing WISeR in New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington. The model pays private companies to use AI to approve or deny essential medical services and devices, including for Parkinson’s, chronic pain, sleep apnea, and wound care. These companies are paid a percentage of the value of the services they deny, creating a clear incentive to deny care.

“While prior authorization is often described as a cost-containment strategy, in practice it increases provider burden, takes time away from patients, limits patients’ access to life-saving care, and creates unnecessary administrative burden,” the lawmakers wrote.

Unlike Medicare Advantage, traditional Medicare rarely requires prior authorization. For patients with traditional Medicare, treatments are determined by doctors and not by insurance companies. The use of prior authorization has steadily increased, with Medicare Advantage insurers making roughly 50 million prior authorization determinations in 2023. Ultimately, over 80% of denials are overturned on average.

“Prior authorization has long been abused. It is bad for patients and providers. The WISeR Model only perpetuates the harm that prior authorizations can cause,” the lawmakers continued.

Implementing the WISeR Model for traditional Medicare had already started putting beneficiaries at greater risk of having needed care and treatments denied. A recent Seattle Times story documents how Washington seniors are having pain care denied and forced to suffer while their prior authorization is processed.

The full letter can be found here.