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CMS is requiring one of the companies it hired to use artificial intelligence to review prior authorization requests under the WISeR prior authorization pilot to submit a corrective action plan because it allegedly was not responding to claims quickly enough, NPR affiliate KUOW reported June 25.
Why Virtix Health Faces Scrutiny Under the WISeR Prior Authorization Pilot
Virtix Health, a Phoenix-based healthcare technology and utilization-management company, failed to meet the pilot’s 72-hour turnaround for prior authorization and pre-payment determinations, according to the report. This failure to meet processing timelines triggered the corrective action requirement under the broader WISeR prior authorization pilot framework.
What the WISeR Pilot Tests
CMS’s Wasteful and Inappropriate Service Reduction model launched Jan. 1 in Arizona, Ohio, Oklahoma, Texas, Washington and New Jersey. The pilot runs through Dec. 31, 2031, and tests whether enhanced technologies, such as artificial intelligence and machine learning, can streamline prior authorization and medical review for items and services vulnerable to fraud, waste, abuse or inappropriate use.
How CMS Is Responding to Delays in the WISeR Prior Authorization Pilot
Virtix was audited across five areas following complaints about operational delays: clinical determinations, communications, portal functionality, customer service and timeliness. Federal officials will now hold biweekly meetings with Virtix to track progress, a heightened oversight cadence reflecting the seriousness of the compliance issues found under the WISeR prior authorization pilot.
How Virtix Is Compensated
Virtix is compensated based on a share of averted Medicare expenditures under the program, a payment structure that has drawn its own scrutiny given the financial incentive it creates around denial and cost-reduction outcomes. Virtix did not respond to a message from Becker’s seeking comment.
Congressional Pushback on the WISeR Prior Authorization Pilot
The WISeR program has been scrutinized by some federal lawmakers. The House Appropriations Committee on June 9 moved forward with an amendment that would block federal funding for the program. “The committee believes that any proposal to impose prior authorization requirements in traditional Medicare should be subject to robust congressional oversight and transparent evaluation of impacts on beneficiary access to care, provider burden and program costs,” the amendment said.
A Call for More Transparency
The amendment also called for CMS to provide an update in its fiscal 2028 congressional justification on the selection of states and the pilot’s impact on patients. On June 22, more than two dozen House lawmakers sent a letter to CMS Administrator Mehmet Oz, MD, requesting data on appeals and denials during the WISeR prior authorization pilot‘s first six months, according to the report.
Processing Times Have Reportedly Improved
CMS said turnaround times, which averaged about five days in the program’s first four months, have since improved to 1.7 days for prior authorization and just over three days for prepayment review, according to the report. This improvement suggests CMS’s corrective action process may already be producing measurable results, even as the broader program continues to face funding threats.
What Comes Next
With Virtix now under biweekly monitoring, congressional lawmakers requesting detailed appeals and denial data, and a funding amendment moving through the House Appropriations Committee, the WISeR prior authorization pilot faces mounting pressure on multiple fronts simultaneously. How CMS balances continued vendor oversight with the program’s broader survival amid congressional scrutiny will likely shape whether WISeR expands, stalls, or gets defunded before its scheduled 2031 conclusion.
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