WASHINGTON – Medicare began reviewing a list of procedures in advance in six states on 1 January 2026.
The companies that grant or refuse that review are paid out of money Medicare does not spend.
That is not an allegation. It is in the government’s own notice. The Federal Register notice says participants are “compensated based on a share of averted expenditures.”
The program is called the Wasteful and Inappropriate Services Reduction model, or WISeR. It covers Medicare fee for service. It runs in New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington, through 31 December 2031.
About 1,000 pages of records were released to the Electronic Frontier Foundation. The group obtained them through freedom of information litigation and reported on them on 8 September 2026.
Contents
Which care is on the list, and where#
The notice lists fifteen items and services, each tied to an existing national or local coverage document. CMS’s provider fact sheet counts fourteen.
They are not exotic procedures. The list includes epidural steroid injections for pain management, excluding facet joint injections. It includes arthroscopic lavage and debridement for the osteoarthritic knee, cervical fusion, and vertebral augmentation for a compression fracture. It also includes incontinence control devices and hypoglossal nerve stimulation for obstructive sleep apnea. Skin and tissue substitutes are on the list too, but only where an active local coverage document exists, which is not every state.
Two of them are not running. In April 2026 CMS published a the April 2026 notice delaying two of the services. They are deep brain stimulation for essential tremor and Parkinson’s disease, and image guided lumbar decompression for spinal stenosis.
The delay is open ended. CMS says the two wait for “a future date that will be announced in a subsequent Federal Register notice.”
Until then neither prior authorization nor pre-payment review applies to those two. So the list in force today is shorter than the list in the founding notice.
Each item is tied to an existing Medicare coverage document. Those documents say when a service is covered. The notice says the model “will not change payment or coverage for the selected services in the model.” It changes who checks, and when.
One company works in each state. Cohere Health covers Texas. Genzeon covers New Jersey. Humata Health covers Oklahoma. Innovaccer covers Ohio. Virtix Health covers Washington. Zyter covers Arizona.
Doctors get a choice of two paths. They can ask for approval first. Or they can go ahead and have the claim reviewed before payment. The provider fact sheet says there is “no change in provider payments or providers’ appeal rights.”
Who signs a refusal, and who pays them#
A machine cannot decide against payment on its own here. CMS has said so in two places.
The model page says every recommendation for non-payment is made by “appropriately licensed clinicians.” The provider fact sheet says who those clinicians work for. Its words: “clinicians employed by these companies will review non-affirmation requests.”
Both sentences matter. A person signs the refusal, and that person works for the company rather than for Medicare.
Prior authorization itself is not new here. The notice says CMS “has implemented prior authorization in Medicare FFS under specific and limited initiatives …” What is new is the money position of the reviewer.
A share of averted expenditures means one thing. The less Medicare pays out on these services, the more the company earns.
The payment method is not a side effect. It is one of the things the model is testing. The notice lists it among the model’s objects.
“a novel payment approach that is based on paying WISeR participants a share of averted expenses in lieu of the traditional acquisition-based approach …”
CMS built guardrails. A clinician must sign. Quality scores adjust payment. The Electronic Frontier Foundation reports that a low quality score cuts payment by only 5 to 10 percent.
Still, a reader deciding whether to worry should know one thing. The reviewer earns more when the answer is no.
What the first records show#
The numbers below come from the Electronic Frontier Foundation’s reading of the records. They are that group’s account, not our own count. The 1,000 pages have not been read here.
Two companies together refused 5,944 requests in the first three months, the group reported. The group also reported that Virtix Health refused more requests than it approved in that period.
EFF reports that CMS expects a decision within 72 hours. No CMS document we hold names that number. EFF also reports a status report describing a request that went unanswered for 83 days.
EFF’s account also quotes a provider: “We have patients calling our offices crying in pain because their procedures are being delayed …”
Those pages have not been read line by line for this article. The case file is public. Reading it is the next step, not a conclusion already reached. A claim that has been checked is not the same as a claim that has been read, and checking one is a skill.
What a refusal does and does not mean#
A refusal here is called a non-affirmation. The notice is specific about what comes next.
A provider may try again, within a limit the notice sets. Where the service has yet to be provided and no claim has gone in, the provider “has unlimited opportunities to resubmit a prior authorization request.” On a second try the notice says the provider may request “a peer-to-peer review to inform the new determination.” It does not say who that peer is.
A refusal also does not close the door. In the notice’s words, it “does not prevent the provider/supplier from submitting a claim.” The claim is then denied. The notice says that denial “would constitute an initial determination, which would be subject to the administrative appeals process.”
There is a faster track when waiting is dangerous. A doctor may ask for an expedited review when the normal timeline “could jeopardize the life or health of the beneficiary.”
What happens next#
The model has five more years scheduled. Two services wait on a date CMS has not set. CMS says it is also looking at “gold carding,” which would exempt compliant providers. The notice sets the bar at a 90 percent affirmation rate, and says full compliance “may not be necessary.”
Three things hold today for a Medicare beneficiary in those six states. The notice says coverage and payment for the listed services do not change. A refusal must carry a licensed clinician’s decision. And appeal rights are unchanged.
Background is in AI is deciding Medicare coverage and when a machine decides.
Source: Federal Register notice 2025-12195, published 1 July 2025, full text read; Federal Register notice 2026-06616, published 6 April 2026, full text read; the CMS WISeR model page and provider fact sheet; and the Electronic Frontier Foundation’s account of records released in its litigation against CMS, read 18 September 2026, 8 September 2026.