Weekend Interlude: Who’s Really Making Medicare Decisions?

Every once in a while, the weekend asks for something a little different. Today it asks for clarity—on Medicare, algorithms, and the decisions being made for us.

Before anything else, here is what WISeR actually stands for:

WISeR = Wasteful and Inappropriate Services Reduction Model

A new Medicare pilot that uses algorithmic tools to decide whether certain procedures are “necessary.”

1. What “AI” Really Is — and Isn’t

Most people think “AI” is one giant machine or one powerful company.

It isn’t.

“AI” is a nickname for software programs written by people—hundreds of different systems, built by many private companies, each with its own incentives, limits, and error rates.

This is why the word artificial misleads people. It makes the technology sound distant or magical, when we’re really talking about human-created software—programmers writing algorithms for many purposes, including cost cutting.

2. Why WISeR Matters

WISeR is the first major effort to bring AI-assisted prior authorization into traditional Medicare.

There is still a lot we don’t know:

• how often medically needed care will be denied,

• whether prior authorization will cause dangerous delays,

• how appeals will work,

• what datasets train the algorithms,

• or how errors will be identified and corrected.

But we now know this:

The people deciding are not your doctors.

They are not Medicare.

CMS recently confirmed that the WISeR pilot will operate in six states from January 1, 2026 through December 31, 2031 — and will rely on six private technology companies to perform the algorithmic reviews.

These companies—not Medicare physicians—will determine whether seniors receive care.

And each company is paid a percentage of the “savings” generated by reducing or denying services.

References

1. Centers for Medicare & Medicaid Services (CMS): WISeR Model Fact Sheet

2. CMS: WISeR Provider and Supplier Operational Guide

3. KFF Health News: Medicare’s new AI-assisted prior authorization pilot raises concerns

4. Medicare’s WISeR Model and the Challenge of Low-Value Care (Health Affairs)