In Letter to RFK Jr., Cantwell Demands Changes to New AI-Driven Prior Authorization Program That’s Overruling WA Doctors and Delaying Care for Seniors

In Letter to RFK Jr., Cantwell Demands Changes to New AI-Driven Prior Authorization Program That's Overruling WA Doctors and Delaying Care for Seniors

WA hospitals report extended delays for authorization under WISeR pilot program, WA seniors report crippling pain while they wait for treatment; ICYMI: Cantwell presses RFK on AI-driven care denials in hearing; details delays in care and patient suffering in snapshot report

WASHINGTON, D.C. - Today, U.S. Senator Maria Cantwell (D-WA), senior member of the Senate Finance Committee and ranking member of the Senate Committee on Commerce, Science, and Transportation, called on U.S. Health and Human Services (HHS) Secretary Robert F. Kennedy, Jr. to urge greater transparency and quicker care through the Centers for Medicare and Medicaid Services's (CMS) new artificial intelligence (AI) driven prior authorization program, called the Wasteful and Inappropriate Service Reduction (WISeR) Model.

"By CMS's own benchmark, the model is not meeting expectations in Washington state which is resulting in significant burdens on patients and providers. For instance, CMS committed to responding to claims within 72 hours, but Washington providers report they are waiting 15 to 20 days for determinations, which are most often denials issued without any clear justification. Further, according to the Washington State Hospital Association, procedures that were typically completed within two weeks prior to WISeR now take four to eight weeks. That frequently forces patients to reschedule care multiple times, prolonging pain and allowing underlying conditions to worsen.

"At the same time, CMS has structured the WISeR model in a way that financially rewards contractors for delaying or denying care. A misaligned incentive structure that claims to boost efficiency but risks restricting access for vulnerable seniors," Sen. Cantwell wrote in a letter to RFK Jr.

Under RFK Jr.'s leadership, HHS launched the WISeR model on Jan. 1, 2026 across six states. In those states -- Arizona, New Jersey, Oklahoma, Ohio, Texas, and Washington - Medicare patients are subject to prior authorization requirements for 13 types of procedures or treatments, meaning that a claim needs to run through an opaque A.I. driven system that may deny it with no explanation, starting the whole process over again and setting the patient back weeks in the process.

Sen. Cantwell continued in her letter: "Specifically, I am seeking your commitment to the following:

• Require contractors administering WISeR to respond to standard claims within 72 hours and urgent claims within 24 hours.
• Require that any denial issued through WISeR include a written explanation authored by a human reviewer, not AI.
• Prohibit contractors administering WISeR from assigning appeals to individual billing staff, rather than the responsible provider or facility.
• Improve transparency by publicly reporting the number of denials issued through WISeR and the financial gains realized by contractors administering the program.
• Prohibit contractors administering WISeR from denying care when a patient's medical team has documented that reasonable alternatives have been considered and ruled out.
• Before expanding the WISeR program, provide Congress with a written analysis of the results of the pilot program."

A new snapshot report released yesterday by Sen. Cantwell's office including new data from the Washington State Hospital Association shows that patients dealing with WISeR are waiting two to four times longer to get the care recommended by their doctors - from a previous average of around two weeks to the current average of four to eight weeks.

Also yesterday, Sen. Cantwell questioned Sec. Kennedy about WISeR during a Senate hearing.

"A.I. is being used as a denial device for the CMS system. And it's apparently had some problems where, it's not taking a few days to find out whether you're going to get covered or not -- it's basically taking weeks to find out that you're denied, on things that never were a prior denial before," Sen. Cantwell told RFK Jr. in a hearing of the Senate Finance Committee yesterday.

"We have hospitals calling me about this, I have doctors calling me about this, I have patients calling me about this. So, I would appreciate if you take a look at it."

RFK Jr. responded: "That kind of delay is unacceptable, and we will work with you on it."

Sen. Cantwell said: "The scary thing about A.I. is that if we really think we're going to put A.I. in charge of deciding [care] instead of doctors, I think we're going to have some real problems."

READ MORE:

The Spokesman Review: Cantwell warns RFK Jr. his agency's AI program is delaying, denying Medicare for seniors in Washington state

KHQ: Senator Cantwell questions health secretary on A.I. tool delaying care for seniors

Video of their exchange is HERE; a transcript is HERE.

In their survey of three hospital systems with 16 hospital locations spanning across the State of Washington, WSHA heard directly from its members how WISeR has impacted care for Medicare patients since Jan. 1:

• Authorization times for many medically necessary procedures have gotten longer (from about 2 weeks to 4-8 weeks)
• Delays mean patients are experiencing prolonged pain and reduced mobility, and some are turning to alternative treatment methods (For example: One of the most common procedures that now requires prior authorization under WISeR is an epidural steroid injection for back pain. Facing long approval delays and dealing with pain/limited mobility, some patients - who previously had no problem getting the procedure approved under Medicare - are now turning to opioids to help manage the pain)
• Claims are being sequenced based on authorization timing rather than clinical need
• Denials are often inconsistent with clinical criteria and lack clear reasoning

Sen. Cantwell's full snapshot report with more exclusive data and statements on the impacts of WISeR is HERE.

The full text of today's letter is HERE and below:

Dear Secretary Kennedy,

I write to follow up on our exchange yesterday during your testimony before the Senate Finance Committee and request that the U.S. Department of Health and Human Services commit to enhanced transparency and timely delivery of care through the Centers for Medicare & Medicaid Services' (CMS) new artificial intelligence (AI) driven prior authorization program, called the Wasteful and Inappropriate Service Reduction (WISeR) Model.

As we discussed at the hearing, I have heard significant concerns from my constituents - including patients, doctors, and hospitals - that in practice, the WISeR model is having negative impacts on health care for Washingtonians. Instead of detecting fraud and reducing waste, it is increasing inefficiency for providers. To illustrate these significant problems, I shared the story of one Washingtonian, whose access to vital treatment was needlessly delayed. You agreed "that kind of delay is unacceptable, and we will work with you on it." You also said there are "probably kinks in the system" and pledged to work with me to "straighten it out." I appreciate that offer of cooperation and am sharing additional information about my state's experiences with WISeR.

As you know, since January, CMS has been piloting the WISeR model in six states: Arizona, New Jersey, Oklahoma, Ohio, Texas, and my home State of Washington. I understand that WISeR relies on AI, machine learning, and contractor-led clinical review to apply controversial new prior authorization requirements to traditional Medicare. Currently, the model covers 13 services, including epidural steroid injections for pain management, minimally invasive treatments for spinal stenosis and osteoarthritic knees, and nerve stimulation therapies for conditions like sleep apnea and incontinence.

By CMS's own benchmark, the model is not meeting expectations in Washington state which is resulting in significant burdens on patients and providers. For instance, CMS committed to responding to claims within 72 hours, but Washington providers report they are waiting 15 to 20 days for determinations, which are most often denials issued without any clear justification. Further, according to the Washington State Hospital Association, procedures that were typically completed within two weeks prior to WISeR now take four to eight weeks. That frequently forces patients to reschedule care multiple times, prolonging pain and allowing underlying conditions to worsen.

At the same time, CMS has structured the WISeR model in a way that financially rewards contractors for delaying or denying care. A misaligned incentive structure that claims to boost efficiency but risks restricting access for vulnerable seniors. In Washington state, the WISeR pilot is administered by CMS contractor Virtix Health, which has implemented practices that can further delay and deny care. For example, WISeR limits access to prior authorization information to the individual employee who submitted the request. If that employee is unavailable due to illness, leave, or departure, the request may become inaccessible or even canceled, forcing patients and providers to repeat the process.

These delays have real consequences for patients. The Washington resident whose story I shared at the hearing is Keith Magnuson, an 83-year-old who lives in Seattle, Washington. Keith was once highly active, regularly walking up to six miles per day. Today, he suffers from lumbar spinal stenosis, a debilitating condition that has drastically limited his mobility. As a result, Keith can barely walk 100 yards without experiencing severe pain. His physician recommended a minimally invasive outpatient procedure known as MILD, a commonly used treatment for this condition that is typically covered by Medicare. However, under the WISeR Model, a portion of his treatment was denied. As a result, this previously active individual has been forced to significantly scale back his daily activities due to the limitations and delays caused by the approval process. As a result, he is now taking oxycodone - an opioid - every day to manage his pain.

Keith is far from the only Washingtonian in this situation. At the University of Washington Medical Center alone, more than 100 patients are currently awaiting approval for similar procedures.

I support the responsible use of new technologies, including artificial intelligence, to improve care delivery. However, the WISeR model, as currently implemented, is using these tools in ways that obstruct timely access to medically necessary care.

I appreciate that at yesterday's Finance hearing you pledged to work with me on these issues. Specifically, I am seeking your commitment to the following:

• Require contractors administering WISeR to respond to standard claims within 72 hours and urgent claims within 24 hours.
• Require that any denial issued through WISeR include a written explanation authored by a human reviewer, not AI.
• Prohibit contractors administering WISeR from assigning appeals to individual billing staff, rather than the responsible provider or facility.
• Improve transparency by publicly reporting the number of denials issued through WISeR and the financial gains realized by contractors administering the program.
• Prohibit contractors administering WISeR from denying care when a patient's medical team has documented that reasonable alternatives have been considered and ruled out.
• Before expanding the WISeR program, provide Congress with a written analysis of the results of the pilot program.

Sincerely,