A top Trump administration official recently acknowledged issues with the program, but the administration has shown no signs of nixing it. #
A federal program testing whether artificial intelligence and other technologies can help Medicare reduce wasteful spending ran into problems after a rushed start, according to Freedom of Information Act documents the Electronic Frontier Foundation released Tuesday.
Technology companies have used AI in six states to help human clinicians determine whether Medicare will cover select services since the beginning of the year, when CMS launched the program known as the WISeR model. Services undergoing AI-assisted coverage reviews have included skin substitutes and electrical nerve stimulator implants.
Hospital groups and members of Congress have criticized the initiative for delaying medical care for seniors and burdening medical providers with extra paperwork.
But the Centers for Medicare and Medicaid Services also raised concerns with the WISeR model, informing four of the program’s six vendors of issues earlier this year, per the newly released documents.
Three of the vendors — Genzeon Corporation, Virtix Health and Zyter — received requests for information from CMS outlining problems like reports of slow coverage determinations and questionable coverage denials. The fourth company — Innovaccer — received two requests for corrective action plans from CMS, which sought step-by-step plans to address issues, documents revealed.
“These newly released documents show that the WISeR rollout was rushed and rocky from the start, highlighting the dangers that arise when governments treat AI like a silver bullet for complex problems,” EFF wrote in a Tuesday blog post about the documents.
Companies respond to CMS concerns
CMS sent Genzeon Corporation — the WISeR vendor for New Jersey — a Feb. 6 request for information citing a backlog of coverage determination cases as of Jan. 27 and the mistaken creation of duplicate unique tracking numbers for cases. The company implemented corrective actions to address the issues and had more fixes in progress, according to a Feb. 13 response letter.
Medical providers complained that Virtix Health — the WISeR vendor for Washington — issued slow Medicare coverage determinations, questionable denials and blank determination letters, according to a March 17 letter from CMS.
The company acknowledged the concerns but said “the majority of requests requiring clarification involved provider misunderstanding” of the WISeR model, according to a March 24 response letter to CMS. Virtix Health added that provider misunderstanding had “improved meaningfully over time” thanks in part to active “provider education efforts.”
Because of that provider education work, “63.7% of requests are affirmed during individual reviews, the affirmation rate increases to 84.3% after providers have the opportunity to resubmit with improved documentation,” the company told Nextgov/FCW.
CMS required Virtix Health to submit a corrective action plan because the company did not respond within the 72-hour turnaround time for approvals, NPR affiliate KUOW reported in June. Though it’s unclear when the company got a corrective action plan request, CMS has said the turnaround time issue has been corrected, the outlet reported.
That corrective action plan closed on Aug. 14 and, since the first quarter, Virtix Health has reduced the average turnaround time for prior authorization to 1.18 days and 1.17 for prepayment review, the company told Nextgov/FCW.
CMS told Zyter — the WISeR vendor for Arizona — in a Feb. 27 letter that it received reports that the company was not issuing timely determination letters and may have lacked adequate processes for escalating provider concerns.
Zyter attributed technical challenges to the “accelerated implementation timeframe and compressed onboarding timeline” for its participation in WISeR, according to a March 5 response letter. CMS launched the WISeR model less than six months after announcing it.
Zyter’s March 5 letter detailed actions the company took to address concerns along with additional plans.
Zyter “promptly addressed” early WISeR model implementation concerns alongside CMS, company CEO Sundar Subramanian told Nextgov/FCW.
Zyter’s provider portal “has been operating successfully for more than six months, with authorization determinations routinely processed within minutes or near real time, and timely issuance of determination letters to providers and beneficiaries,” Subramanian added.
Innovaccer — the WISeR vendor for Ohio — received a Jan. 7 request from CMS for a corrective action plan, alleging its early implementation of the pilot did not comply with program requirements, such as responding to providers electronically.
The company said in a Jan. 16 letter it was compliant with all program requirements except for the requirement that it maintain a secure electronic portal for coverage pre-approval submissions. The company added that it warned CMS it would not have that portal ready by WISeR’s launch through October and December 2025 letters.
Innovaccer received another corrective action plan request on Feb. 20 after CMS concluded it did not comply with the first plan the company submitted. In that second request, CMS said the provider portal Innovaccer promised to work on was not yet fully functional by a Feb. 5 deadline. The company maintained it complied with WISeR model requirements and requested a meeting with CMS, according to a Feb. 27 response letter.
Innovaccer’s provider portal is currently “fully live,” the company told STAT in September, though it did not say when it went live.
Genzeon Corporation, Innovaccer and CMS did not respond to requests for comment by publication.
The letters released Tuesday add to early WISeR model issues revealed by FOIA documents released by EFF in September.
“I HAVE HAD TO WATCH 3 PATIENTS CRY AT BEDSIDE FOR NOT HEARING BACK ON THEIR PRIOR AUTH FOR KYPHOPLASTY/VERTABRAL AUGMENTIATION [sic] PROCEDURE. THESE PATIENTS ARE IN DEEP PAIN,” one Ohio-based provider wrote in a March feedback survey released by EFF.
Ongoing scrutiny
Lawmakers and hospital groups have continued to scrutinize the WISeR model.
The House Appropriations Committee advanced a bipartisan amendment that would suspend funding for the WISeR model and other pilots testing coverage determinations in traditional Medicare.
Amid the scrutiny, the Trump administration has not signaled it will end the WISeR model.
“There are a lot of things about WISeR that are not working,” Kimberly Brandt, CMS deputy administrator, acknowledged at a conference last month.
“I don't have an answer for you in terms of what's going to fix it,” Brandt said in response to a conference attendee.
But “there are a lot of things that [the CMS Innovation Center, which oversees the WISeR model, is] trying to fix on this, and especially because of the congressional scrutiny on this, they are committed to trying to get that right and get it better,” she continued.
Meanwhile, Senator Elizabeth Warren, D-Mass., wrote in September that documents suggest CMS plans to expand the WISeR model to additional services, including oncology care and cardiac catheterization.
Chris Klomp — who was then a nominee for Health and Human Services Deputy Secretary — did not confirm CMS plans to expand the pilot in response to Warren’s question.
He did, however, say CMS is monitoring the pilot’s processing time, provider burden, beneficiary experience, access, clinical quality and savings in response to another senator’s question.
“Decision[s] about changes to the model would be based on such experiences and findings,” Klomp wrote.