A Model With a Name Like a Compliment
CMS, the federal agency that runs Medicare, has given its new prior-authorization AI pilot a name that sounds almost self-deprecating: WISeR, for Wasteful and Inappropriate Service Reduction. It launched January 1 in six states. Private technology vendors were brought in to run the reviews, because nothing says "trust the government" quite like outsourcing the government's judgment to a company with a financial interest in the outcome.
That interest, sources confirm, is not subtle. Vendors are compensated in part on the volume of services they deny, with a cut of up to 20 percent of the resulting "savings." The Algorithm does not need to understand a patient's condition to grasp the assignment.
The Numbers Do Some of the Talking
In Texas, only 62 percent of WISeR requests were approved on first pass — before a wave of human reviewers stepped in and pushed that number up to 84 percent. The national approval rate for traditional Medicare Advantage, for context, sits around 92 percent. The gap between what the machine decided and what humans corrected is, one presumes, exactly the kind of daylight a pilot program is supposed to close, not open.
The Machine was, again, working precisely as incentivized.
Asking Nicely, Then Asking a Judge
The Electronic Frontier Foundation filed a Freedom of Information Act request back in March, seeking basic details: what data trains the model, what safeguards exist against bias, whether anyone audits it at all. CMS, in a development that will surprise no one who has been paying attention, did not answer. So EFF sued.
The lawsuit does not allege the algorithm is wrong. It alleges the public isn't allowed to check. Investigators note this is, in its own bureaucratic way, an even more damning position — nobody at the agency has claimed the system is fair, because nobody outside it has been permitted to look.
CMS was unavailable for comment, in the sense that it was available and simply did not comment.
The Waiting Room Has a New Occupant
Patients denied care under WISeR can still appeal, in theory, to a human being. Whether that human being has the authority, time, or incentive to overrule a system whose vendor gets paid more for saying no is a question the pilot program does not appear eager to answer either.
Progress, like sewage, is most detectable after it has reached the basement.
Sources: EFF — EFF Sues for Answers About Medicare’s AI Experiment · Healthcare Dive — Tech nonprofit sues CMS over Medicare AI prior authorization pilot
