What Exactly Is WISeR?

by Alvin Blackshear  |  Historian & Researcher  <ablackshear@gmail.com> 

A Deeper Look at Medicare's AI Prior Authorization Pilot

A lot of you wrote in after “Is AI Deciding Who Gets Healthcare?” asking the same question: okay, but where, and for what?  Fair ask. Here are the details.

The Basics

WISeR stands for Wasteful and Inappropriate Service Reduction. It's a six-year model run by Centers for Medicare & Medicaid Services' (CMS) Innovation Center, announced in June 2025 and live since January 1, 2026. Unlike Medicare Advantage, where prior authorization has been standard for years, WISeR marks one of the first real tests of AI-assisted prior authorization inside original (fee-for-service) Medicare, a program that has historically had almost none of it. CMS frames the goal as trimming fraud, waste, and abuse. Critics frame it as outsourcing coverage denials to vendors whose paychecks depend on how much they deny.

Which States

WISeR is currently running in six states, split across four Medicare Administrative Contractor jurisdictions:

●        New Jersey

●        Ohio

●        Oklahoma and Texas

●        Arizona and Washington

CMS chose these based partly on which states' MAC jurisdictions and existing local coverage rules made the model easiest to test cleanly. There's no public timeline yet for expanding beyond these six, but several health-finance analysts expect that if the pilot runs smoothly, CMS won't wait out the full six years before widening it.

Which Procedures

For the initial phase, WISeR covers 14 selected Medicare Part B services, all elective rather than emergency or first-line treatments. The list centers on categories CMS has flagged as historically vulnerable to overbilling or overuse, including:

●        Skin and tissue substitutes (grafts used in wound care)

●        Electrical nerve stimulator implants

●        Epidural steroid injections for pain management

●        Knee arthroscopy for osteoarthritis

CMS has said it may add services to this list as the model progresses. Notably excluded: inpatient-only services, emergency services, and anything CMS considers too risky to delay.

Who's Actually Doing the Reviewing

This is the detail that surprises people most: the “model participants” aren't providers or insurers; they're technology companies. CMS selected six of them to operate the AI/ML-driven review process across the six states: Cohere, Genzeon, Humata, Innovaccer, Virtix, and Zyter.

Here's roughly how it works. A medical provider can either submit a request for prior authorization before performing the service, or skip that step and submit the claim for a post-service, pre-payment review instead. If they go the prior-authorization route, the AI vendor is supposed to return a determination (an affirmation or non-affirmation) within about three days. Any non-affirmation (denial) has to go through a licensed clinician before it's finalized; CMS says the AI itself can't issue the final “no.”

The Part That Worries Critics

The vendors' compensation is tied, at least in part, to the savings their reviews generate, meaning the more claims they flag as non-payable, the more they can earn, adjusted against other metrics like accuracy and provider experience. Revenue-cycle experts have publicly guessed that a meaningful share of claims routed through WISeR (some estimates run around 25%) could end up denied. That incentive structure is central to why members of Congress introduced the Ban AI Denials in Medicare Act, aiming to shut the model down before it expands further.

CMS is also piloting a “gold-carding” feature, expected to roll out further details later in 2026, that would exempt providers with consistently clean approval histories from future prior-authorization requirements, an attempt to reward compliance rather than blanket every claim with review.

The Takeaway

WISeR is narrower than my original article may have implied: six states, 14 services, six named vendors, with a human clinician required to sign off on any denial. But the financial incentives baked into the model, and the fact that this is the first large-scale AI prior-auth experiment inside traditional Medicare, are exactly why it's worth watching closely as it expands.

Sources

CMS, “WISeR (Wasteful and Inappropriate Service Reduction) Model”: https://www.cms.gov/priorities/innovation/innovation-models/wiser

CMS, “WISeR Model Frequently Asked Questions”: https://www.cms.gov/priorities/innovation/files/document/wiser-model-frequently-asked-questions

CMS, “WISeR Fact Sheet”: https://www.cms.gov/files/document/wiser-fact-sheet.pdf

CMS, “WISeR Model Provider and Supplier Operational Guide”: https://www.cms.gov/priorities/innovation/files/wiser-provider-supplier-guide.pdf

Nick Hut, “The WISeR prior authorization model for Medicare is set to pose challenges for hospitals,” HFMA (Dec. 23, 2025): https://www.hfma.org/revenue-cycle/the-wiser-prior-authorization-model-for-medicare-is-set-to-pose-challenges-for-hospitals/

ASRA Update, “CMS Provides More Details on WISeR Prior Authorization Model” (Oct. 24, 2025): https://asra.com/news-publications/asra-update-item/asra-updates/2025/10/24/cms-provides-more-details-on-wiser-prior-authorization-model

Dinsmore & Shohl, “Is AI WISeR? CMS Models AI-based Prior Authorization Process in Six States” (Jan. 30, 2026): https://www.dinsmore.com/publications/is-ai-wiser-cms-models-ai-based-prior-authorization-process-in-six-states/

Moss Adams, “Medicare WISeR Model Requires Prior Authorizations in Six States” (Jan. 13, 2026): https://www.mossadams.com/articles/2026/01/medicare-wiser-model

DLA Piper, “CMS launches WISeR Model: What providers need to know” (2026): https://www.dlapiper.com/en/insights/publications/2026/01/cms-wiser-model

Center for Medicare Advocacy, “Early Reports on WISeR Model Are Troubling” (Mar. 26, 2026): https://medicareadvocacy.org/early-reports-on-wiser-model-are-troubling/

Congressional Research Service via Congress.gov, “Overview of the Medicare Wasteful and Inappropriate Service Reduction (WISeR) Model” (May 12, 2026): https://www.congress.gov/crs-product/IF13133

Medical Economics, “WISeR spending or unneeded delays in health care? Prior authorizations, AI in Medicare prompt concerns” (July 15, 2026): https://www.medicaleconomics.com/view/wiser-spending-or-unneeded-delays-in-health-care-prior-authorizations-ai-in-medicare-prompt-concerns

Is AI Deciding Who Gets Healthcare?

by Alvin Blackshear  |  Historian & Researcher   <ablackshear@gmail.com>

“AI is now deciding who gets healthcare in six US states.” It is the kind of sentence built to travel fast, and for older Americans who have spent decades trusting that traditional Medicare would simply pay for what their doctor ordered, it lands like an alarm. So is it true? Is artificial intelligence actually deciding whether Medicare patients receive medical treatment, or does that framing exaggerate what the federal government is actually doing?

The honest answer sits in uncomfortable middle ground. The underlying story is substantially real. Medicare has launched an important and controversial experiment involving AI-assisted prior authorization. But describing this simply as “AI deciding who gets healthcare” leaves out critical details about human review, existing Medicare coverage standards, the narrow set of services involved, and the difference between a coverage determination and a physician’s decision to provide care. At the same time, legitimate concerns about delays, financial incentives, transparency, and algorithmic influence should not be waved away merely because a headline overstates the case.

What Exactly Is WISeR?

The program at the center of the controversy is the Wasteful and Inappropriate Service Reduction Model, known as WISeR, created by the Centers for Medicare & Medicaid Services (CMS). It began operating on January 1, 2026, with prior authorization requests starting January 5 and application to relevant services beginning January 15. The model is scheduled to run through December 31, 2031. It applies to selected services under Original Medicare, not Medicare Advantage, and it operates in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. CMS says the purpose is reducing fraud, waste, abuse, and low-value medical care, and the program targets a defined list of procedures and services rather than all Medicare-covered healthcare. In July 2026, the Senate voted against an effort to overturn WISeR, allowing the pilot to continue.

This distinction matters: WISeR is not an AI system reviewing every Medicare patient’s medical care. It is a technology-assisted prior-authorization and prepayment-review system covering a specific set of services that CMS considers vulnerable to inappropriate utilization, fraud, waste, or abuse.

Is AI Actually Making the Decision?

This is the question at the heart of any honest fact check. CMS explicitly permits WISeR contractors to use technologies including artificial intelligence and machine learning. But CMS also states that appropriately trained clinicians participate in verifying whether requests satisfy Medicare’s coverage requirements. Three claims deserve to be separated. It is accurate to say AI is being used as part of Medicare’s prior-authorization process. It is potentially misleading to say AI independently determines whether a beneficiary may receive healthcare. The more precise formulation is that private contractors use AI and machine learning-assisted systems together with clinical review to determine whether certain services meet Medicare coverage requirements.

There is also a distinction often lost in the headlines: a Medicare coverage decision is not identical to a medical decision. A physician can recommend a procedure while Medicare separately determines it will not pay for it. For many patients, however, that distinction can feel largely theoretical. If Medicare declines to pay for an expensive treatment, the practical result is often that the patient cannot obtain it at all.

Why CMS Built the Program, and Why Critics Are Worried

CMS argues that wasteful healthcare spending represents a significant share of American medical expenditures, and that the services selected for WISeR already have established coverage criteria, generally involve elective rather than emergency treatment, carry safety concerns when performed unnecessarily, and have histories of fraud or inappropriate use. Emergency and inpatient-only services fall outside the program entirely. The government’s argument, in short, is not that AI should practice medicine. It is that technology can more efficiently determine whether a procedure satisfies existing Medicare rules before taxpayers pay for it.

Critics raise four distinct concerns. Prior authorization already generates substantial complaints within Medicare Advantage and private insurance, so extending it into traditional Medicare marks a meaningful policy shift. Proprietary AI systems create questions of explainability, since physicians and patients may not know precisely how a case was evaluated. The payment structure has also drawn scrutiny because contractors can benefit financially from savings generated by preventing expenditures, which critics argue could incentivize denials, even as CMS maintains that contractors are simply rewarded for catching genuinely wasteful spending. Finally, human review does not automatically eliminate algorithmic influence. Even when a clinician confirms a determination, the AI system may shape which cases get flagged and what information the reviewer ultimately sees, which raises a harder question: when does AI merely assist a decision, and when does it effectively shape it?

Are Patients Already Being Harmed?

This claim deserves particular caution. There are documented reports of authorization delays, and Senator Maria Cantwell (Washington-D) released a 2026 report citing Washington hospital data suggesting that patients undergoing WISeR-covered procedures experienced substantially longer processing times. But documented delays, denied payment, allegations of denied medically necessary care, and proof that AI itself caused measurable patient harm are not interchangeable claims. A responsible account should avoid concluding that AI is harming Medicare patients unless evidence establishes the full chain from algorithm to incorrect determination to delayed or denied treatment to actual harm. That evidence remains under active investigation.

The Transparency Problem

The Electronic Frontier Foundation has filed a federal Freedom of Information Act lawsuit seeking information about WISeR’s underlying AI systems, including details on algorithms, vendor arrangements, accuracy testing, bias testing, hallucinations, and ongoing monitoring. This creates an unusual situation: the federal government is testing AI-assisted healthcare decision-making while the information needed to independently evaluate those systems may not yet be public. That does not prove the algorithms are unsafe. It establishes that independent verification remains difficult.

Misinformation, or an Oversimplified Warning?

Calling the original claim simply “misinformation” would go too far. The essential facts are real: Medicare is testing technology-enabled prior authorization involving AI and machine learning in six states, private contractors are participating, and coverage determinations can affect patients’ access to particular procedures. But “AI is deciding who gets healthcare” is more sweeping than the evidence supports.

The more consequential story may be the quieter one. For decades, Americans have debated whether insurers and government bureaucracies should second-guess physicians’ medical judgment. Artificial intelligence has now introduced a new actor into that old dispute. The sharper question is not simply whether AI is denying healthcare. It is how much influence an algorithm should have over a decision that can determine whether a patient can actually afford to follow their doctor’s advice, and what standard of evidence the government should have to meet before allowing an opaque system to shape that decision at all.

References:

CMS, WISeR Provider and Supplier Operational Guide. https://www.cms.gov/priorities/innovation/files/wiser-provider-supplier-guide.pdf

CMS, WISeR Request for Applications. https://www.cms.gov/files/document/wiser-model-rfa.pdf

KFF, Examining the Potential Impact of Medicare’s New WISeR Model, February 10, 2026. https://www.kff.org/medicare/examining-the-potential-impact-of-medicares-new-wiser-model/

Congressional Research Service, “Overview of the Medicare Wasteful and Inappropriate Service Reduction (WISeR) Model,” updated May 12, 2026. https://www.everycrsreport.com/reports/IF13133.html

Federal Register, CMS, original WISeR implementation notice, July 1, 2025. https://www.federalregister.gov/documents/2025/07/01/2025-12195/medicare-program-implementation-of-prior-authorization-for-select-services-for-the-wasteful-and

Sen. Maria Cantwell, WISeR Snapshot Report, 2026. https://www.cantwell.senate.gov/imo/media/doc/wiser_snapshot_report.pdf

EFF v. CMS, federal complaint, filed March 25, 2026.

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Ten Great Novellas

There's something wonderfully sneaky about the novella. It's not quite a short story, not quite a novel. It's the literary equivalent of a perfect afternoon: long enough to get lost in, short enough to finish before dinner. Clocking in anywhere from 60 to 160 pages, the novella is the ideal training ground for a young writer and the ideal companion for a reader who wants a complete emotional journey without a two-week commitment. It's a form that rewards precision, and the ten books below prove just how much power a writer can pack into so few pages.

Seven of these came to me the way they come to most of us: as required reading in high school, dog-eared and highlighted under fluorescent classroom lights. Animal Farm by George Orwell taught a generation of teenagers that pigs make surprisingly effective political satirists. The Metamorphosis by Franz Kafka turned a man into a bug and, somehow, made it feel like the most relatable Monday morning ever written. The Stranger by Albert Camus introduced us to existentialism before we even knew what to call it, while Of Mice and Men by John Steinbeck broke hearts on schedule every spring semester.

Then there's Heart of Darkness by Joseph Conrad, dense and haunting, sending readers up the river long before Coppola sent Martin Sheen. The Old Man and the Sea by Ernest Hemingway showed that a story about one man, one fish, and one very long fight could still feel like an epic. And The Third Man by Graham Greene rounded out the classroom curriculum with shadows, zithers, and moral ambiguity in postwar Vienna.

But graduation didn't end the reading list. It just paused it. The remaining three have been waiting for me ever since, and I'm delighted to finally be catching up. Stephen King's Rita Hayworth and Shawshank Redemption proved that the master of horror could write hope just as convincingly as he writes dread. Denis Johnson's Train Dreams is a quiet, aching marvel, the story of one ordinary life told with the patience of a river carving canyon walls. And Patrick Rothfuss's The Slow Regard of Silent Things is a strange, tender little book that breaks nearly every rule of storytelling and somehow becomes more magical for it.

What strikes me, moving between the assigned classics and these later discoveries, is how little the form has changed even as the stories have. Whether it's a talking pig, a giant marlin, or a girl who lives in the walls of an underground school, the novella still does what it's always done best: it gets in, breaks your heart or blows your mind, and gets out before you've had time to catch your breath. Ten books, ten very different worlds, and not a wasted page among them.

Animal Farm by George Orwell (1945)

The Metamorphosis by Frans Kafka (1915)

The Stranger by Albert Camus (1942)

Of Mice and Men by John Steinbeck (1937)

Heart of Darkness by Joseph Conrad (1899)

The Old Man and the Sea by Ernest Hemingway (1952)

The Third Man by Graham Greene (1950)

Rita Hayworth and Shawshank Redemption by Stephen King (1982)

Train Dreams by Dennis Johnson (2011)

The Slow Regard of Silent Things by Patrick Rothfuss (2014)

Frederick Douglass's American Founding: How the Nation’s Fiercest Critic Embraced the Constitution - REVIEW

by Dennis C. Rasmussen 

The remarkable story of how Frederick Douglass went from condemning the Constitution as a proslavery pact to celebrating it as a “glorious liberty document” that promises freedom to everyone

The speeches and writings of Frederick Douglass contain some of the most probing examinations ever of the role that slavery played in America’s founding. In Frederick Douglass’s American Founding, Dennis Rasmussen traces the great abolitionist’s intellectual journey from denouncing the founders as hypocrites and the Constitution as evil to embracing them both.

Throughout the 1840s, Douglass described the founders as “little better than a band of pirates” and the Constitution as “a most cunningly-devised and wicked compact.” Beginning in 1849, however, he undertook a long period of study and reflection that produced a dramatic change of mind. From 1851 on, Douglass contended that the founders were resolutely opposed to slavery and that the Constitution was a “glorious liberty document” that mandated immediate emancipation, despite several clauses that appeared to suggest otherwise. Even after embracing the Constitution and the founders, Douglass remained second to none in castigating America for the evils of slavery. Indeed, as he argued in his greatest speech, “What to the Slave Is the Fourth of July?” (1852), the glory of the nation’s founding ideals only put their persistent betrayal into starker relief. Douglass also came to regard the founders as radicals in their fight against tyranny. That was why he insisted that he and his fellow abolitionists, rather than moderates like Abraham Lincoln, were the founders’ true heirs.

At a time when Americans are turning to the founding with renewed interest thanks to the 250th anniversary of 1776, it is also worth our while to look anew at Frederick Douglass, for his speeches and writings contain some of the most probing examinations ever of the role that slavery played in the founding era. They are all the more fascinating because he dramatically changed his mind about the founding midway through his career.

In the early part of his career-throughout the 1840s-Douglass denounced the founders as wicked oppressors and the Constitution as emphatically proslavery. During this period he was a sort of forerunner of the recent 1619 Project.

From 1851 onward, however, Douglass contended that the founders were resolutely antislavery and that the Constitution was a "glorious liberty document." Here he bore a greater resemblance to the explicitly patriotic 1775 Report.

However, Douglass's mature view of the founding avoids the pitfalls of the dominant perspectives of this period in today's culture wars. He combined deep admiration for the nation's birth with radical criticism of the nation itself.

Strikingly, after Douglass embraced the founding he grew more open to the use of violence against slaveholders, thereby growing more radical in one sense even as he seemed to grow more moderate in another.

In contrast to virtually every historian today, Douglass interpreted the pre-Reconstruction Constitution as an abolitionist charter-one that, if faithfully executed, would have required emancipating every enslaved person in the U.S.

Frederick Douglass's American Founding utilizes several previously unexamined editorials written by Douglass, including one on Thomas Jefferson's notorious racism.

Whatever you think about the founding, Douglass’s arguments will challenge—and perhaps even change—your views. After seeing the Constitution through Douglass’s eyes, it is difficult to look at it in the same way again.

Dennis C. Rasmussen is professor of political science and the Hagerty Family Fellow at Syracuse University’s Maxwell School of Citizenship and Public Affairs. His books include Fears of a Setting Sun: The Disillusionment of America’s Founders and The Infidel and the Professor: David Hume, Adam Smith, and the Friendship That Shaped Modern Thought (both Princeton University Press).

Princeton University Press
ISBN-13: 978-0691294025