AI Now Decides if Texas Medicare Patients Receive Certain Types of Care

Since Jan. 15, Texas Medicare patients who need a skin graft, a nerve stimulator, or one of 12 other specific procedures must pass an AI-powered checkpoint. In Texas, the Wasteful and Inappropriate Service Reduction (WISeR) Model is a federal program run by a private AI company whose profits are derived from a percentage of the care it helps deny from Medicare patients.

Dr. Mehmet Oz and the Centers for Medicare & Medicaid Services created WISeR in June 2025, despite calling prior authorization “a pox on the system” at his Senate Finance Committee confirmation hearing last March. Prior authorization, or PA, is the process of obtaining approval from an insurance company to ensure they will cover a prescribed medication or procedure.

WISeR is one of the largest expansions of prior authorization in the 60-year history of traditional Medicare, and Texas is one of six pilot states – not because we volunteered, but because CMS decided that Texas demonstrates the “presence or absence of selected services,” along with other factors. 

WISeR is classified as a “voluntary” model on its website. Though marketed as an optional way to implement “safe and evidence-supported best practices for treating people with Medicare,” it is only optional for the vendors – for-profit companies like Cohere Health, which is responsible for overseeing WISeR in Texas. (Neither CMS nor Cohere Health responded to requests for comment.) The Texas Medical Association wrote that anesthesia, emergency medicine, and wound care are just three of the “specialties expected to be most impacted.” Although it impacts all Medicare recipients, Texas physicians say many of their colleagues don’t even know the program exists. And if the providers aren’t aware, patients almost certainly aren’t either.

“Some physicians are saying they have really not heard about the portals,” Dr. Jayesh Shah, former TMA president, told the Chronicle, referring to the WISeR dashboards where physicians submit documentation. “There is still [a] need for more education in that area.”

According to Dr. Jack Resneck, former president of the American Medical Association, prior authorization often involves a vast amount of paperwork. “For the medications or procedures that do require prior auth, it’s a bit of a guessing game. We don’t actually know what piece of information the health insurer is looking for, so we send a bunch of explanations,” Resneck explained in an interview on AMA’s website. “But if it doesn’t exactly match what the health plan employee is looking for on their computer screen, then oftentimes it won’t get approved – even if it’s justified and evidence-based.” 

Programs that require extensive prior authorization processes delay medically necessary care. A letter from the AMA to CMS strongly disavowing WISeR’s prior authorization requirement stated, “93 percent of physicians reported that PA causes care delays, 82 percent indicated that the process can lead to treatment abandonment, and an alarming 29 percent said that PA had led to a serious adverse event (hospitalization, disability, or even death) for a patient in their care.”

“The documentation process [for WISeR] is almost similar to what you [see] for prior auth with Medicare Advantage,” said Shah. “It won’t be anything different.”

Medicare Advantage pays private, for-profit insurers a fixed amount per patient – and prior authorization is required for the majority of procedures to conserve costs. A 2022 federal investigation by the Health and Human Services Office of Inspector General found that Medicare Advantage plans denied 13% of prior authorization requests that fully met Medicare’s coverage requirements. When patients appealed those denials, about 75% were overturned in their favor, suggesting the original denials were systematically wrong. A January Kaiser Family Foundation study found that the rates were almost identical over the last few years: Each year, around 10% of patients appealed, and 81% were overturned again – but the number of requests had jumped to 53 million per year. Patients’ access to care was routinely blocked. Many seniors chose traditional Medicare to avoid that issue, only to see prior authorization reintroduced through WISeR – a model that puts their medical access in the hands of AI instead of a human health plan employee.

“Some physicians are saying that they’re getting more denials, and it’s just not worth the hassle factor,” Shah said.

“The procedure is indeed confusing,” David Lipschutz, co-director of law and policy at the Center for Medicare Advocacy, wrote in an email to the Chronicle. “A provider can choose to submit an unlimited number of prior authorization requests, but if denied, there is no way to appeal – Another request must be submitted. A provider can choose not to obtain prior authorization and provide the services, but … receive more scrutiny and more uncertainty about whether they will be paid, which could influence providers’ willingness to render services.”

Texas politicians raised alarms about WISeR months before the program went live. In a July 2025 letter to Dr. Oz and Abe Sutton of CMS, four Texas Congress members warned that paying private companies based on a share of denied care meant those companies “will be paid more if they deny more prior authorization requests, thus incentivizing restrictions of necessary care.” Signatories included Austin’s Lloyd Doggett and Greg Casar, Houston’s Sylvia Garcia, Fort Worth’s Marc Veasey, and 38 of their House colleagues.

Perhaps most concerning is that most outside CMS do not know how the AI model works. The Electronic Frontier Foundation sued CMS in March seeking basic records about WISeR’s algorithm – including how it was tested for accuracy and bias – but has received no response. After 42 members of Congress raised formal objections and a federal lawsuit demanded answers, CMS moved forward anyway. Now, Texas Medicare patients may be denied care by a program whose inner workings remain secret.

[Editor’s note: We originally stated that Cohere Health oversees WISeR in Oklahoma and Texas. They only operate in that capacity in Texas. The Chronicle apologizes for the error.]

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