The headline is that Washington Rep. Suzan DelBene (D) and five other House Democrats have introduced a bill to repeal the WISeR Model, a tool the Centers for Medicare and Medicaid Services (CMS) will use in six states starting in January to implement AI-driven prior authorization requirements for eliminating waste and fraud in certain Medicare Part B activities.

The six lawmakers object to WISeR on the grounds it represents harmful, additional red tape for Medicare beneficiaries.

Beyond the headline, and of importance to skilled nursing sector stakeholders, are issues tied to the precedent WISeR sets, and how far you want to read into its significance, said leading Medicare expert Jay Gormley, COO, Advisory, Zimmet Healthcare Services Group.

‘Slippery Slope’ or Not?

He said “one’s position on this proposal largely depends on how much tolerance one has for the potential ‘slippery slope’ it represents. The targeted conditions appear to be reasonable areas, which have been the subject of Dept. of Justice enforcement actions and have been specifically addressed in some recent rulemaking around the physician fee schedule.”

The six-year CMS Innovation Center (CMMI) demonstration (Jan 1, 2026 – Dec 31, 2031) initially focuses on curbing unnecessary spending in:

• Electrical nerve stimulation devices

• Epidural steroid injections

• Knee arthroscopy

• Other services under LCDs/NCDs with high denial variability

Still, Gormley said the very act of introducing prior authorization requirements into the fee-for-service (FFS) Medicare program marks a notable departure from precedent.

“Historically, such mechanisms have not been widely applied within FFS, and certainly not in contexts where the reviewing entity is financially incentivized to limit service utilization,” he said. “The explicit reliance on AI models adds another layer of concern, as similar systems used by Medicare Advantage plans have drawn scrutiny for denying care not on the basis of medical necessity, but rather on the likelihood that beneficiaries would forgo the appeals process.”

What Is WISeR?

The WISeR model introduces AI-driven, prospective utilization review, a major shift from retrospective audits. It uses machine learning and predictive analytics to identify questionable claims before payment.

The two key interventions are prior authorization (required before a service is rendered) and pre-payment review, which is conducted after service but before reimbursement.

WISeR will be implemented in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington and covers four Medicare Administrative Contractor jurisdictions. It is mandatory for providers performing selected services in those areas. But it is voluntary for technology vendors, who are paid via shared savings (a percentage of cost reductions).

Much Ado About . . . ?

In the end, Gormley said on balance, “the model’s narrow geographic focus and its limitation to a discrete set of procedures [many of which CMS itself characterizes as having limited clinical value] suggests that the practical implications may be relatively contained. This may ultimately prove to be a policy issue where the political risks do not warrant significant opposition at this stage.”

There is no immediate impact on core SNF services, but it demonstrates CMS’s growing commitment to data-driven, prospective oversight an early warning of what’s likely coming for all providers, he noted.

The group of six House Democrats who introduced the Seniors Deserve SMARTER (Streamlined Medical Approvals for Timely, Efficient Recovery) Care Act, include Reps. DelBene, Greg Landsman (OH), Ami Bera (CA), Kim Schrier, (WA), Mark Pocan (WI), and Rick Larsen (WA).

The legislation has been endorsed by numerous provider and advocacy groups, including the Washington State Medical Association, Texas Medical Association, Physicians for a National Health Program, Social Security Works, and others.

Comments or questions, contact Patrick Connole at pconnole@parkplacelive.com.