Congressional Opposition to WISeR Model Demands Performance Data From CMS
A congressional coalition sent a letter on June 22 to Centers for Medicare and Medicaid Services (CMS) Administrator Mehmet Oz, M.D., expressing...
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Stakeholders within the medical community are applauding congressional efforts to delay rollout of the Centers for Medicare & Medicaid Services Wasteful and Inappropriate Service Reduction (WISeR) Model for prior authorization in Medicare Advantage.
On Nov. 13, several medical professional organizations, including the College of American Pathologists, sent a letter of commendation to Reps. Tom Cole (R-Okla.) and Rosa DeLauro (D-Conn.), from the Committee on Appropriations in the House of Representatives. A unanimously adopted amendment to the appropriations bill for fiscal year (FY) 2026, originally offered by Rep. Lois Frankel (D-Fla.), would halt the implementation of prior authorization for select services using the WISeR Model, which uses artificial intelligence to root out wasteful spending on approvals the model deems unnecessary.
“This action appropriately pauses the rollout of WISeR, creating necessary time to address fundamental concerns with the model’s design and implementation,” the organizations write.
The stakeholders urged the committee to consider:
- delayed implementation of the WISeR model until Jan. 1, 2027, at the earliest;
- assessment of the cumulative administrative impact of WISeR alongside other new and existing programs;
- establishment of strong oversight to ensure binding payment, prohibit retroactive denials, and prevent excessive denials;
- implementation of gold-carding programs to exempt consistently compliant physicians;
- a requirement for vendors to disclose any criteria, algorithms, or tools used to make determinations; and
- elimination of denial-based payment incentives.
Congress passed a short-term resolution (H.R. 5371) on Nov. 12, funding the government through Jan. 30, 2026, while the House and Senate continue to reconcile their versions of the final appropriations bill for FY2026. The WISeR Model will remain on track to be funded beginning Jan. 1, 2026, unless the amendment survives the reconciliation process and successfully halts funding for the program upon passage of the FY2026 budget.
Sources:
https://docs.house.gov/meetings/AP/AP00/20250909/118593/HMKP-119-AP00-20250909-SD003.pdf
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