In the News

As anxiety over artificial intelligence rises, some members of Congress are taking aim at the Trump administration’s controversial AI model to combat Medicare fraud.

House Democrats and a few Republicans are pushing for more transparency around the payment model, known as WISeR, after a tranche of government records showed it was delaying patient care.

The Centers for Medicare and Medicaid Services launched the model this year in six states. Providers in those states must get approval from a verified third-party vendor before performing six services CMS says are at a high risk of fraud, such as skin substitutes. The preapproval process, called prior authorization, is a common tool insurers use to control costs by requiring a doctor to get payments approved by insurers before performing medical procedures or writing prescriptions.

Prior authorization is used primarily in privately run Medicare Advantage plans and in some Medicaid managed care plans, but less so in traditional Medicare that pays providers for individual services.

Democrats, who have pushed back on the model since it was announced last year, say they're concerned it's an end run to privatize Medicare and enable for-profit entities to deny medical care to patients.

“The more that American seniors learn about WISeR, the more they are outraged that the Trump administration is allowing tech companies to profit by delaying and denying necessary care,” Rep. Suzan DelBene (D-Wash.), a leading critic of the model, said in a statement to POLITICO.

The third-party vendors rely on AI to sift through clinical evidence delivered by physicians as part of their requests for payment approval, but CMS has said human clinicians make the final denials.

That explanation hasn't satisfied some doctors and hospitals who say using AI to assess claims could lead to patients being inappropriately denied care. Major advocacy groups, such as the American Medical Association and the American Hospital Association, are against the model.

But some providers who are responsible for monitoring their Medicare spending have lauded the model for attempting to stop fraudulent payments. Chief among them is skin substitutes, a wound care treatment that shot up to $15 billion in Medicare spending last year.

The model’s use of AI comes amid increased scrutiny of the AI industry on Capitol Hill this week after revelations from several former AI researchers about the potential harms the technology could have on humanity. But while AI anxiety among lawmakers has skyrocketed, there has been little consensus on how to regulate it, especially for health care.

New concerns

Opponents of the model pointed to a tranche of more than 1,000 pages of CMS records obtained by the civil liberties advocacy group Electronic Frontier Foundation after a Freedom of Information Act lawsuit.

The files showed problems with delays in answering requests from providers participating in WISeR.

The documents included a feedback form for one of the third-party tech vendors, Innovaccer, which showed more than two dozen complaints from providers about poor communication from vendors and long wait times for answers to requests. Innovaccer, which did not return a request for comment, handles prior authorization requests for model participants in Ohio.

CMS said in a statement to POLITICO that the data released in the records is from the “earliest months of WISeR implementation” and doesn't reflect current performance.

“When interpreting this data, it is important to account for the different outcomes a prior authorization request may have,” CMS said. “In addition to affirmations and non-affirmations, requests may be dismissed because they are incomplete, contain invalid information, or fall outside the scope of the WISeR Model.”

CMS added that it will release a report card for the first six months of the model, which launched in January.

WISeR is a part of a larger CMS effort to stop fraudulent payments at the agency. Traditionally CMS identifies payments that have already gone out and attempts to claw back funding if it is linked to fraudsters, a costly and burdensome process.

Democrats have been critical of the WISeR model since it was announced in summer 2025, but GOP support for the model also appears to be slipping.

During a House Ways and Means Committee markup on Wednesday, DelBene introduced an amendment to force CMS to disclose any audits or corrective action plans the agency has for the third-party vendors and to require the independent Medicare Payment Advisory Commission panel to examine cost-control practices such as prior authorization.

While the amendment was voted down, largely along party lines, it garnered support from Republican Rep. Mike Kelly of Pennsylvania. Kelly told POLITICO after the hearing that he's been working with DelBene on prior authorization reform for years and the amendment wasn't controversial. He didn’t comment on whether he wants the model to be nixed.

“I just thought it made sense. I thought the amendment was fine,” he said.

Several other House Republicans voted in favor of DelBene’s amendment before switching their votes at the last minute.

“It was a remarkable display to see Republicans recognize there was a problem there, to vote for it and get leaned on by their chair for no reason other than it wasn’t in his markup,” said Rep. Lloyd Doggett (D-Texas), top Democrat on Ways and Means’ health subcommittee.

Chairman Jason Smith (R-Mo.) did not return a request for comment on the markup amendment vote.

While efforts to fix prior authorization have traditionally been bipartisan, Republicans have been reticent to criticize WISeR, especially as the party has made combating fraud a top priority ahead of the midterms.

‘Common ground’

On the same day as the markup, Chris Klomp, a top health department official, acknowledged concerns about the model during his confirmation hearing to be the department's deputy health secretary.

Sen. Patty Murray (D-Wash.) asked Klomp about WISeR during his hearing before the Senate Health Committee. Murray said seniors in her state were experiencing delays in their care and asked whether third-party vendors were being incentivized to deny them.

Murray said she was worried the model would be expanded to include services beyond the six high-risk ones the agency originally approved.

Klomp said he understood her concerns and explained that third-party vendors will face financial penalties if they deny care inappropriately. If the model isn't working, he won't expand it, Klomp told Murray, adding that one of his family members had to deal with a six-week wait for prior authorization.

“You and I are in common ground on this topic. It must be done appropriately or it should not expand,” he said.