Democrats in the House are making a push to roll back the Trump administration's new prior-authorization demonstration.
A group of six Dems, led by Washington Rep. Suzan DelBene, have introduced new legislation that would roll back the Wasteful and Inappropriate Service Reduction, or WISeR, model, which was unveiled earlier this year by the Centers for Medicare & Medicaid Services (CMS).
Under the model, the agency will lean on chosen tech vendors to implement new artificial-intelligence-powered prior authorization requirements in six states, beginning in January 2026. The White House argues that this move is aimed at addressing fraud and waste, while the legislators said that it instead amounts to additional red tape in Medicare.
The representatives note in an announcement that the model comes in the same year that CMS is touting its role in pushing insurers to make pledges to ease prior authorization burdens.
"We know that prior authorization in Medicare Advantage and elsewhere ultimately limits access to care, increases the burden on loved ones and care providers, and leads to worse health outcomes,” DelBene said in the press release.
“The administration has publicly admitted that prior authorization is harmful, yet it is moving forward with this misguided effort that would make seniors navigate more red tape to get the care they’re entitled to," she continued. "Congress needs to step in and protect seniors, their families and healthcare workers by stopping this model."
The debate over prior authorization is a common one in healthcare, particularly in the Medicare Advantage space. The legislators point to a 2018 Office of Inspector General analysis that found 75% of denied MA claims were ultimately approved upon appeal.
A 2022 analysis from HHS found that many Medicare Advantage insurers flout coverage rules around prior auth, and that the American Medical Association found that close to a third of docs report that prior authorization led to a serious adverse medical event for a patient.
At the same time as the representatives were making a push to pull back the model, CMS announced the initial group of vendors that will be participating in WISeR.
There will be a different tech provider for each state, according to the site for the model:
- Arizona: Zyter
- New Jersey: Genzeon Corporation
- Ohio: Innovacer
- Oklahoma: Humata Health
- Texas: Cohere Health
- Washington: Virtix Health