The simplicity of Traditional Medicare has been its main strength over the decades, as long as your doctor claimed you required a procedure, you received it. However, beginning January 1, 2026, that scene is changing radically to 6.4 million Americans. A pilot program currently being launched has recently added Artificial Intelligence (AI) to the list of 17 most frequent medical procedures, which are generally being approved, prompting pressing concerns about patient access, and the future of elderly care.
The WISeR Model: Reduce Wasteful Care or Reduce Benefits?
This initiative is formally called the Wasteful and Inappropriate Service Reduction (WISeR) model and is a six-year pilot project initiated under the Trump administration that is said to focus on low-value services that CMS (Centers for Medicare & Medicaid Services) considers to yield minimal clinical value and cost the taxpayers billions.3 As cited in the article by Abe Sutton, the Director of the CMS Innovation Center, as much as 25 percent of U.S. healthcare expenditure is wasted. In 2022 alone, it is estimated that about 5.8 billion was used on services that have little benefit. CMS believes that by applying AI to signal these processes prior to occurrence, the problem of waste, fraud, and abuse will be tamed.
The 17 Processes that AI is Currently Subjected to.
In New Jersey, Ohio, Oklahoma, Texas, Arizona, or Washington, your physician can now be required to request permission of an AI algorithm regarding various outpatient services. The targeted list is directed at procedures that are traditionally associated with the high level of improper billing:4
*Pain Management: Epidural steroid injections and home based spinal injections.5
Surgical Interventions: Knee arthroscope (osteoarthritis), cervical fusion, PVA.6
Medical devices: nerve-stimulator implants: electrical; incontinence control devices; skin/tissue implants (chronic wounds).7 • Special care: Deep brain stimulation (Parkinson/Essential Tremor) and diagnosis/ treatment of impotence.8
The program does not cover emergency services and inpatient-only procedures, to which delaying could be a significant danger to a patient.
The Effect on the Elderly and the Physicians.
Doctors in the six pilot states threaten unintended consequences. Prior authorization in Traditional Medicare was traditionally infrequent – it took place only in approximately 0.01% of services. By contrast, private Medicare Advantage plans make almost two determinations on an enrollee basis.
Key Concerns for Patients:
1. Delayed Care: Although expedited requests have a 72-hours limit, the treatment can be delayed by the paperwork.12
2. Provider Burnout: Small practices can be unable to manage the piles of paperwork and new electronic submission portals.13
3. Algorithmic Bias: There is still a fear that AI is not sensitive enough to the specific medical needs of the elderly.
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