WIKIMEDIA COMMONS | Georgetown faculty and students have expressed concerns about the Centers for Medicare and Medicaid plan to launch a pilot program, Wasteful and Inappropriate Service Reduction (WISeR) Model, Jan. 1, 2026, in an effort to remove “wasteful spending” from the programs in six different states.
The Centers for Medicare and Medicaid are planning to launch a pilot program Jan. 1, 2026, in an effort to remove “wasteful spending” from the programs in six different states. Georgetown faculty and students have expressed concerns about patient access and privatization with this new program.
The program, known as the Wasteful and Inappropriate Service Reduction (WISeR) Model, will hire private insurance companies to leverage artificial intelligence (AI) and sift through Medicare insurance claims en masse. Many experts and critics of the policy say that it will lead to mass denials and delays of care that are reported to be deeply unpopular with Americans.
Prior authorization, the requirement that providers get approval from insurers before covering a procedure or service, is often used in private insurance spheres and has been at the center of multiple lawsuits due to its alleged tendency to reject large groups of care claims for patients.
With insurance coverage denials increasing in recent years and AI taking a central role in review processes for insurance companies, many are skeptical of applying this same method to traditional Medicare, which some see as a first step to privatizing the public program.
Carrie Graham — the executive director of Georgetown University’s Medicare Policy Initiative, a research center offering evidence-based policy recommendations for Medicare — said individuals eligible for Medicare benefits have a few options.
“When someone becomes eligible, they have a choice to make,” Graham wrote to The Hoya. “Do they stay in the traditional Medicare program where they can go to any doctor in the country, with no restrictive provider network, and very little need for prior authorizations for Medicare covered services; or do they choose to enroll in a Medicare Advantage plan that is run by a private managed care company.”
Medicare Advantage has used this technology with its claimants, and some Medicare experts warn that bringing AI into traditional Medicare plans could make denials for procedures more commonplace.
There are also mounting concerns about the financial incentives of companies to deny claims, with Medicare promising a share of the savings that come from procedure denials, creating further friction between insurers and physicians.
Graham said this same struggle causes many issues for patients who may need a necessary procedure when utilizing private insurers.
“In the last few years, there has been quite a bit of push back from consumers and their doctors/providers that insurers are going overboard with prior authorization, denying care that is medically necessary and causing delays in care,” Graham wrote.
Graham recounted the story of an Instagram influencer and plastic surgeon, Dr. Elisabeth Potter, who recently had to call her patient’s insurer, United Healthcare, while her patient was in the operating room about to undergo a procedure for breast cancer, saying this type of situation could become more likely.
“You can see a social media personality like Dr. Potter who does videos about all the paperwork and burden it causes to have to get authorizations for breast surgeries,” Graham wrote. “It has gained a lot of attention.”
Graham also said that the use of the AI program in Medicare Advantage (MA) plans, which are offered by private companies with Medicare benefits, has had its strengths in how it can prevent low-value care that does not provide much benefit.
“MA plans do a good job of stopping ‘low value’ care that is costly and not very helpful to patients,” Graham wrote.
Cait Donohue (SOH ’28) said she worries most about the accessibility of patient care.
“As a student studying Healthcare Management and Policy, I’m especially concerned about the patient experience,” Donohue told The Hoya. “While it’s reasonable for Medicare to look for ways to reduce unnecessary spending, the use of AI-driven prior authorization raises serious questions.”
While there have been many instances of wasteful spending in traditional Medicare, especially with the skin substitutes controversy earlier this year, there is also significant concern with the slippery slope — that is, the extent of procedures that companies are willing to deny, which could potentially include lifesaving interventions.
Jack Hoadley, a research professor emeritus at the Georgetown Medicare Policy Initiative, says that there is still quite a way to go before this AI program can be integrated with Medicare.
“This new initiative raises significant risks for beneficiaries who participate in the traditional Medicare program,” Hoadley wrote to The Hoya. “There are key questions — around the use of artificial intelligence methods, beneficiary awareness, and potential denials and delays of care — that should be addressed before this new program is implemented.”
Donohue said that the patient should come first in medical access situations.
“Cost savings should never come at the expense of timely access to essential care.”