The Pulse
Medicare’s WISeR Pilot Pays Contractors for Qualifying Denials
Records obtained by the Electronic Frontier Foundation show that Medicare’s WISeR pilot pays contractors for qualifying denials, with payment adjustments tied to decision quality. The records also document thousands of denials and long auth
AI.info Team ·
Two contractors denied 5,944 Medicare prior-authorization requests in the first three months of the federal WISeR pilot, according to records released September 8 by the Electronic Frontier Foundation. The documents also show that participating companies can receive payments tied to qualifying non-affirmations—decisions that a requested service does not meet Medicare’s coverage criteria.
The Wasteful and Inappropriate Service Reduction model, known as WISeR, uses technology that can include artificial intelligence to review requests for selected services in six states. The payment arrangement has drawn scrutiny because contractors’ compensation can rise when their reviews avert Medicare spending, while providers say delays and denials have disrupted care.
Payment follows a non-affirmation
Under the Centers for Medicare & Medicaid Services’ payment methodology, a contractor may receive a payment after a prior-authorization request is not affirmed, or after a pre-payment review results in a denied claim. The amount is calculated using a regional spending benchmark and adjusted by a discount, a payment rate and a quality adjustment. CMS says it withholds or recoups payment when a denied claim is successfully appealed.
The EFF says the released data guide shows that low quality scores reduce vendor payments by 5% to 10%. The payment formula also includes accuracy and timeliness measures, and CMS says it can impose corrective action plans, withhold payment or terminate a participant for poor performance.
Every non-affirmation must receive review by a qualified human clinician, CMS says. A provider can resubmit a request, seek peer-to-peer review as part of resubmission, or deliver the service and submit a claim; patients and providers retain existing appeal rights.
5,944 denials in three months
EFF’s review of CMS records found that two participating companies denied 5,944 prior-authorization requests during the model’s first three months. Virtix denied more requests than it approved in that period and was required by CMS to submit a corrective action plan, the documents show.
Records also point to delays beyond the program’s expected response window. One request went unanswered for 83 days, EFF reported. The organization cautioned in a correction that reported turnaround times cover the full request pathway and are not controlled solely by WISeR vendors.
Provider feedback included reports of patients waiting in pain for approvals related to procedures. One response quoted in the records said: “We have patients calling our offices crying in pain because their procedures are being delayed while awaiting approvals or guidance tied to this model.”
Launch problems surfaced before rollout
The records show that Innovaccer warned CMS about software readiness roughly a month before WISeR launched in January 2026. The company said its software lacked full functionality and had not been fully tested, citing changing requirements, unclear governance and insufficient time for end-to-end testing with providers.
In a message quoted by EFF, Innovaccer wrote: “Given CMS's decision not to delay the model start date, auto-affirming is the only path available.” The records also describe technical problems and provider complaints after launch.
WISeR operates in New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington, and covers selected services under Original Medicare. CMS says the model does not alter Medicare coverage policy; its stated purpose is to test technology-supported reviews for services it considers vulnerable to waste, fraud or abuse.
The documents leave a pointed tension in the program’s design: CMS ties contractor pay to spending averted while also trying to discourage inaccurate denials through human review, audits, appeals and quality adjustments. The records document the payment mechanism and early operating problems, but do not establish that AI alone made the denials or that every denied request involved medically necessary care.