New documents reveal problems with Medicare's AI prior authorization pilot

Newly released documents obtained by the Electronic Frontier Foundation reveal significant backlogs, technical failures, and treatment delays in the Centers for Medicare & Medicaid Services' AI-based prior authorization pilot, the WISeR model. Launched in January 2026 across six states, the program led to severe delays, with some requests taking up to 83 days and vendors issuing over 20,000 non-affirmations in the first three months. While some physicians report improvements through a 'gold card' bypass program, experts raise concerns over plans to expand the model to urgent care.

WISeR pilot launch delays

• ▪The Wasteful and Inappropriate Service Reduction (WISeR) pilot program is scheduled to run through 2031 to evaluate whether Medicare should adopt the prior authorization process in more states.
• ▪The Electronic Frontier Foundation obtained approximately 1,000 pages of documents through a Freedom of Information Act lawsuit detailing the launch of the Wasteful and Inappropriate Service Reduction (WISeR) model.
• ▪The Centers for Medicare & Medicaid Services launched the Wasteful and Inappropriate Service Reduction (WISeR) AI-based prior authorization pilot program in January 2026 across six states.

Vendor system testing failures

• ▪Electronic Frontier Foundation staff technologist Lena Cohen stated that records show a failure to fully test systems before and after the Wasteful and Inappropriate Service Reduction (WISeR) program launched.
• ▪Prior authorization vendor Innovaccer warned the Centers for Medicare & Medicaid Services on December 12, 2025, that its system lacked full functionality and had not undergone sufficient end-to-end testing.
• ▪Prior authorization vendor Innovaccer temporarily auto-affirmed all prior authorization requests in Ohio for up to 60 days after the January 2026 launch of the Wasteful and Inappropriate Service Reduction (WISeR) model.

Patient treatment delays

• ▪Clinicians reported that patients experienced postponed or canceled medical procedures, such as kyphoplasty, while awaiting approvals under the Wasteful and Inappropriate Service Reduction (WISeR) program.
• ▪Electronic Frontier Foundation's analysis of records showed some prior authorization requests under the Wasteful and Inappropriate Service Reduction (WISeR) program exceeded the 72-hour turnaround, with one request taking 83 days.
• ▪Approximately 30% of the 1,276 direct prior authorization requests received by Virtix Health and Zyter in January 2026 were delayed by 6 to 21 days.

Gold card bypass program

• ▪Arizona interventional pain specialist Matthew Crooks, MD, received a Wasteful and Inappropriate Service Reduction (WISeR) 'gold card' in July 2026, allowing his practice to bypass standard prior authorization.
• ▪Matthew Crooks, MD, stated that while the 'gold card' designation resolved billing and treatment delays for his practice, smaller medical practices face significant barriers navigating the Wasteful and Inappropriate Service Reduction (WISeR) requirements.

CMS contractor oversight issues

• ▪Electronic Frontier Foundation staff technologist Lena Cohen noted that the released documents failed to show what data the Wasteful and Inappropriate Service Reduction (WISeR) AI systems were trained on.
• ▪The Centers for Medicare & Medicaid Services has considered expanding the Wasteful and Inappropriate Service Reduction (WISeR) model to include more urgent services, such as MRI scans and oncology care.

Debatable claims

• ▪CMS should require WISeR contractors to publicly disclose their AI training data
• ▪CMS should not expand the WISeR pilot program to urgent medical services
• ▪CMS should suspend the WISeR pilot program to address system backlogs