Medicare’s WISeR Pilot Program: The Camel’s Nose?
By Jennifer Hanscom
According to a Kaiser Family Foundation survey, one in three insured adults in the United States reports that prior authorization requirements are a major barrier to accessing care. WSMA’s own member surveys tell a similar story: Prior authorization remains one of the most frustrating administrative burdens facing physicians today.
That is why the WSMA immediately raised concerns when the Centers for Medicare and Medicaid Services announced the Wasteful and Inappropriate Service Reduction Model. WISeR is a six-year pilot program intended to reduce fraud, waste, and abuse in Medicare by introducing prior authorization requirements for 13 selected medical services. Washington is among the states chosen to participate in the pilot.
Some have questioned WSMA’s strong opposition to the program. In fact, a former WSMA president recently authored an op-ed in The Seattle Times highlighting the potential benefits of artificial intelligence in helping physicians and health systems identify appropriate care pathways. We recognize and support the goal of reducing unnecessary care and protecting patients. However, we must also ask an important question: Why would we take a process that has long been criticized as burdensome, inefficient, and harmful to patient care and introduce it into traditional Medicare—a program designed for decades to directly cover medically necessary care without the administrative burden of prior authorization?
Even Abe Sutton, director of the Center for Medicare and Medicaid Innovation, has acknowledged that only a small percentage of physicians and practitioners engage in waste, fraud, or abuse. Yet, WISeR applies broadly to physicians and patients who are already navigating a complex health care system.
What concerns us most is that a pilot program is, by definition, a test case. What begins with 13 services today could eventually expand to encompass a much larger portion of Medicare-covered care, becoming in retrospect the proverbial camel’s nose. We cannot afford to ignore the potential consequences for patients and physicians if this model proceeds without rigorous oversight and evaluation.
I don’t need to explain to you the administrative burden associated with prior authorization is already substantial, costly, and has the potential to further endanger patients. A 2024 AMA survey found 90% of physicians reported that prior authorization delays care, with 29% linking such delays to serious adverse events.
Additionally, every hour spent seeking approval for medically necessary care is an hour diverted from patient care. Physicians and their teams are forced to navigate complex, constantly changing, and often non-reimbursable requirements, while patients face delays in receiving treatments, procedures, and medications their physicians have determined are necessary. Even when care is ultimately approved, the process can create unnecessary stress, uncertainty, and risk.
This week, WSMA Vice President Bindu Nayak, MD, joined Rep. Suzan DelBene to highlight the real-world impact that prior authorization delays are having on patients across Washington state. Together, they underscored the importance of ensuring that patients can access timely care based on medical necessity rather than administrative hurdles.
There is encouraging news. Last week, the U.S. House Appropriations Committee advanced an amendment that would prohibit funding for the CMS pilot program that would bring prior authorization requirements into traditional Medicare. While the amendment faces additional legislative hurdles, it represents an important acknowledgment of the concerns raised by physicians, patients, and medical organizations across the country.
The WSMA will continue advocating for policies that reduce administrative burdens, preserve clinical decision-making, and ensure patients receive timely access to the care they need, both in our direct engagement with decisionmakers and through our public messaging, as seen in our ongoing Your Care Is at Our Core campaign. We support efforts to improve the integrity of the Medicare program, but those efforts should strengthen—not hinder—the physician-patient relationship and the delivery of high-quality care.
As you’ll read in the July/August edition of WSMA Reports, reforming prior authorization at the state level continues to be a top priority for the association. In response to commercial carriers using artificial intelligence to streamline processes, Senate Bill 5395 was passed during the 2026 state legislative session to improve transparency and accountability in the prior authorization process. Specifically, the bill prohibits insurance carriers from solely using AI for denials. Only a licensed physician or health care professional working within their scope of practice may deny a prior authorization request based on medical necessity.
Since 2019, the WSMA has also worked at the state level to advocate for simplified processes and tighter turnaround times for prior authorization. We offer the WSMA Prior Authorization Navigator to help members and their practice staff understand what is required for state-regulated insurance plans. For those of you who are impacted by the WISeR pilot program, be sure to review our WISeR model guidance, which includes an operational guide and FAQs.
Our advocacy on prior authorization comes from hearing from members and physician groups in our member surveys and directly about the burdens associated with the processes and their impact on patient care delivery. If your practice or group has a burden it’s struggling with, be it prior authorization, a federal or state regulation, or otherwise, don’t wait for our next member survey. Contact our policy department at any time for help and to keep us informed about the issues impacting your practice and patient care. Our advocacy on your behalf depends on your engagement. Thank you for staying engaged with us.
Jennifer Hanscom is WSMA’s CEO.