Is it likely that the WISeR model will be repealed?

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Is It Likely That the WISeR Model Will be Repealed?

The skinny
In January 2026, CMS launched the Wasteful and Inappropriate Service Reduction (WISeR) model, introducing prior authorization into traditional Medicare for certain services in selected states. However, this controversial program could face a repeal following an effort led by Congressional Democrats this month.

The background
The WISeR model seeks to reduce unnecessary, duplicative and low-value care in traditional Medicare via prior authorization and the use of AI. It's currently being tested in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington, and in partnership with tech vendors Cohere Health, Genzeon Corporation, Humata Health, Innovaccer, Virtix Health and Zyter.

The model is controversial for two main reasons, according to Neil Patil, senior fellow and the policy director at the Medicare Policy Initiative at Georgetown’s Center on Health Insurance Reform. While prior authorization can help reduce wasteful care, it can also lead to denials and delays of necessary care. Prior auth can also increase out-of-pocket expenses for beneficiaries. In addition, the fact that the WISeR model leverages AI is worrying as the technology can lead to more denials and worsen health disparities.

Fight to repeal
As a result, several Congressional Democrats are fighting the implementation of the WISeR model. On May 20, Democrats — including Sen. Ron Wyden (D-Oregon), Rep. Suzan Delbene (D-Washington) and Rep. Greg Landsman (D-Ohio) — introduced a resolution to repeal the WISER model through the Congressional Review Act (CRA). The CRA empowers Congress to review and overturn federal agency rules.

The resolution came after the Government Accountability Office found on May 12 that WISeR imposes new prior authorization requirements on some Traditional Medicare providers, meaning it qualifies as a rule that may be subject to congressional review under the CRA. The CRA requires federal agencies to submit rules to Congress before they take effect, and if they fail to do so, Congress may take steps to repeal the rule.

Could it be repealed?
While repealing the WISeR model has the support of Congressional Democrats, it’s hard to say for sure if it will gain the support of Congressional Republicans and ultimately President Donald Trump, who will need to sign off on it, according to Patil.

“Given that this is the Trump administration's own model that they introduced, I would imagine it's pretty unlikely that the president would go ahead and sign on and terminate this model,” he said. “I would imagine that even if this resolution does pass both chambers of Congress, it's likely it would be vetoed by the President. Now, granted, if it passes both chambers with a lot of support, I think it would be pretty difficult for the president to see that and go ahead and veto it.”

— By Marissa Plescia

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Rocket Pharma Deal Brings In Cash for Gene Therapy Pipeline

The deal
Rocket Pharmaceuticals sold its rare disease priority review voucher to an unnamed large pharmaceutical company for $180 million. With the proceeds, Rocket said its cash position now stands at about $322.6 million, which it expects will support operations into the second quarter of 2028.

The gene therapies
Rocket received the voucher alongside accelerated FDA approval in March for Kresladi, the first gene therapy for leukocyte adhesion deficiency-I (LAD-I), a rare and life-threatening primary immunodeficiency. Such vouchers may be used to speed up the regulatory review of another therapy. But voucher recipients typically opt to sell the regulatory fast passes to big pharma companies as a way to raise non-dilutive capital.

Why this matters
While Kresladi is now Rocket’s first commercial product, analysts have said the more important program for the company is RP-A501, which is in pivotal testing for Danon disease, a rare inherited disorder that leads to heart problems that can become fatal. There are no FDA-approved therapies for Danon. Clinical testing of RP-A501 was temporarily paused last year following a patient death. Last August, the FDA cleared Rocket to resume the trial. The voucher sale extends Rocket’s cash runway, potentially enabling Rocket fund the RP-A501 program to its next data readout.

—By Frank Vinluan

How Is Mayo Clinic Using AI in Its Revenue Cycle?

Drawing a line
Todd Manion, revenue cycle chair at Mayo Clinic, believes that AI can improve revenue cycle workflows, but he doesn’t think the full automation of tasks is coming anytime soon. Clinical complexity doesn't compress neatly into the structured data that automated systems require, he said at HFMA’s annual conference in National Harbor, Maryland.

For instance, he described a scenario he said he has witnessed many times in his career: a physician uses precise clinical language that doesn't translate directly into billing codes. A patient might receive every medication and treatment associated with pneumonia, but if the physician documents the condition as a "pulmonary infiltrate" rather than pneumonia, the coder's hands are tied, Manion explained.

Where AI is working
At Mayo, Manion said AI is already starting to prove its value in the revenue cycle — especially in areas where workflows are repetitive, such as checking claim statuses, flagging outstanding remits and following up on payments that are sitting longer than contractual timelines allow.

Tasks that once required a staff member to wait on hold with a payer can now be handled automatically, freeing that staff member to work on other tasks that actually need their judgment, he noted.

The overarching aim
In general, Manion said he doesn’t think the revenue cycle done is about chasing claims or closing payment gaps. To him, the goal is to accurately reflect the care that was actually delivered.

"If we can do that and do it accurately, everything else falls into place,” he declared.

— By Katie Adams

Medicare Advantage’s Big Decision: Reset or Retreat?

What’s happening?
After years of rapid expansion, expectations around accountability, oversight, and beneficiary protection are becoming clearer, while plans are dealing with higher medical costs and shifting patterns of care. Moments like this can feel disruptive because a lot of long-standing assumptions are being tested at once. But they also create opportunity. A maturing policy environment brings sharper focus on sustainable growth, transparency, and outcomes, rather than just on scale.

A changing dynamic
For much of the program’s expansion, size and growth functioned as insulation. Larger footprints helped plans spread risk, weather changes in utilization, and offset an underperforming market with gains in another. That dynamic is changing. As expectations become clearer and medical costs rise, size alone no longer guarantees stability. Now, size can even work against plans by potentially slowing decision making, weighing them down with legacy systems, and making benefit designs less flexible.

Pressure and opportunity
Although this new environment puts real pressure on smaller and newer MA plans, it also creates real opportunity. While these plans often feel changes in medical costs and utilization more directly, they also bring strengths that larger organizations can struggle to replicate, such as closer relationships with providers, clearer benefit designs, leaner operations, quicker decision making, and a sharper focus on specific populations.

Those advantages matter more when flexibility and focus count more than sheer size. Smaller plans also tend to be more agile in how they adopt technology. With fewer legacy systems and simpler operations, they can often test, adopt, and scale new tools — including AI — more quickly and adapt as technologies evolve. That flexibility can be meaningful in a market where expectations are changing and plans need to respond in real time.

— By MedCity Influencer Deepti Loharikar and Daniel Fellenbaum

Video

Video: How to Think About AI in Prior Authorizations

How should we think about leveraging AI in managing prior authorizations? Matt Parker, chief product officer of Cohere Health, explains three things to watch in this video.

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Is it likely that the WISeR model will be repealed?