The Medicare WISeR experiment. I wasn't aware of this. In case you aren't either, here's the f-ed up deal:

[pat_k]

They are degrading original Medicare Part A and Part B in six states as part of a Center for Medicare and Medicaid (CMS) Wasteful and Inappropriate Service Reduction (WISeR) experiment.

The "incentive structure" shovels a share of the dollars "saved" into the pockets of the technology companies participating in the program.

The six states are Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington (where I live).

The short story is that, in these states, pre-authorization will be required for "targeted services" that are currently covered under Part A and Part B.

This will affect people who keep their Part A and B and purchase a supplement to cover out of pocket costs. Republicans have successfully degraded Medcare Advantage Plans, but have not been able to touch Original Part A and Part B. This sure sounds to me like a "back door" attempt to degrade original medicare with the added bonus of shoveling public funds into the pockets of "technology companies."

The authority under which this program is being implemented is Section 1115A of the Social Security Act.

Some Qs and AI answers

What technology companies are participating?

Specific participating technology companies for the Medicare WISeR (Wasteful and Inappropriate Service Reduction) model are not yet publicly listed as the program is new, but they will be health technology companies using AI and machine learning to manage prior authorization for services like skin and tissue substitutes, electrical nerve stimulators, and knee arthroscopy.

By what authority is CMS implementing this program?

CMS is implementing its Wasteful and Inappropriate Service Reduction (WISeR) Model under the authority of Section 1115A of the Social Security Act. This act created the Center for Medicare & Medicaid Innovation (CMMI), which is authorized to test innovative payment and service delivery models in Medicare and Medicaid to reduce costs while preserving or improving quality of care. The WISeR model, a six-year pilot program beginning January 1, 2026, uses technology-driven prior authorization to target specific services in Original Medicare that have been identified as potentially wasteful or inappropriate.

It sure sounds to me like denying care that was previously covered absolutely violates the requirement of these programs to "preserve" or "improve" care.

Are there any lawsuits against the CMS for violating Section 1115A of the Social Security Act?

No lawsuits have been filed against CMS for the WISeR Model as of late September 2025, but several professional medical societies and lawmakers have expressed strong opposition and concern through letters to CMS due to potential risks of delayed care and increased administrative burdens. While formal legal action hasn't been taken, the significant backlash from key stakeholders suggests the possibility of future litigation if the model's concerns are not adequately addressed by CMS.

An overview of CMS's WISeR program

The model targets specific outpatient services deemed to have limited clinical benefit or be vulnerable to waste, such as certain skin and tissue substitutes and knee arthroscopy for osteoarthritis. Technology companies use artificial intelligence and machine learning to help licensed clinicians assess requests, with participants earning a share of the savings generated by identifying medically unnecessary services.

Targeted Services: The model focuses on specific items and services that may pose patient safety risks if delivered incorrectly or have a history of fraud, waste, and abuse, including certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) and specific musculoskeletal procedures.
Technology Integration: The program leverages AI and ML technology from participating tech companies to assist clinicians in assessing the medical necessity and appropriateness of services.

Incentive Structure: Model participants (technology companies) earn a share of the savings generated by identifying medically unnecessary services.

Review Process: All determinations are made by licensed clinicians using evidence-based criteria to ensure fairness and accuracy.

Exclusions: The WISeR Model excludes inpatient-only services, emergency services, and services that would pose a significant patient risk if significantly delayed.

How were the states selected?

CMS picked six states—Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington—for the Wasteful and Inappropriate Service Reduction (WISeR) model based on a combination of evaluability and operational criteria, including selecting within the same Medicare Administrative Contractor (MAC) jurisdictions to allow for direct comparison between test and comparison states, choosing states with sufficient claims volume for reliable impact estimates, and prioritizing states with existing administrative contractors that already had coverage policies for the targeted services.

Here's a breakdown of the selection criteria and process:

MAC Jurisdictions: The model was assigned to four MAC jurisdictions: JH, JL, JF, and J15.

Within-MAC Comparisons: CMS selected states within the same MAC jurisdictions so they could compare the test states to other states within that same MAC.

Adequate Claims Volume: States were chosen for their sufficient volume of claims, which allows for precise estimates of the model's impact.

Existing Coverage Policies: CMS prioritized states where the administrative contractors already had coverage policies for the services targeted by the model.

Geographic Diversity: The selected states represent diverse geographic areas.

Highest Historical Claim Paid Amounts: States meeting the evaluation criteria were also selected based on the highest historical claim paid amounts.