Prior Authorization Troubles Persist as WISeR Model Faces Scrutiny

Almost one year ago, 50 major health insurers met with U.S. health department leadership and pledged to rein in their use of prior authorization, which patients and providers complain severely disrupts the continuity of care. Now, despite industry studies demonstrating that the practice has been curbed by a little over 10%, the practice continues to cause issues.

Nearly a third of patients report prior authorization as a “major burden” and most describe it as an issue, even after companies volunteered to reduce the number of procedures that would require approval and allow patients to stay on a treatment for 90 days even after switching plans. The New York Times reports that evidence of insurers delivering on these promises is limited. Dr. Archelle Georgiou, a former healthcare executive, attempted an analysis of insurers’ denial rates and found the information limited. Of the data she was able to glean, only 7% of denied claims were appealed and two-thirds of the rejections were reversed on appeal.

The American Medical Association (AMA) released its annual survey of physician practices, and physicians reported that they still complete an average of 40 prior authorization requests per physician per week, and a third of those physicians say those requests are often or always denied.

Commonspirit Health senior vice president of payer strategy Harpreet Cheema told Modern Healthcare that initial prior authorization denials at the health system equate to $3 billion in billed charges, and it saw a 7% increase in denials in the first nine months of fiscal 2026 compared with the year prior. Other systems report that expensive procedures that undergo prior authorization are still subject to secondary review after the procedure occurs.

Senate Democrats, including health committee ranking member Senator Ron Wyden (Ore.) have invoked congressional review of the Wasteful and Inappropriate Service Reduction (WISeR) model. The model allows the Medicare program to contract with private AI companies to implement prior authorization review for certain Medicare-covered services that have been deemed vulnerable to fraud.

Healthcare Dive explains that House Democrats introduced similar legislation last year that didn’t move, but the senators are using the Congressional Review Act, which requires agencies to submit rules to Congress before they can take effect, to challenge the rule. Last week, the Government Accountability Office (GAO) said the rule is subject to the review and the Department of Health and Human Services erred when it failed to submit the model to Congress before its announcement.