Medicare Is Letting AI Say No - and the Companies Doing It Get Paid for Denials

Here’s a business model I’d never have believed if I hadn’t read the contract.

Medicare hires a private tech company to review whether your procedure should be covered. The company uses artificial intelligence to help decide. And the company gets paid a cut of the money Medicare doesn’t spend.

Say no, get paid. Say yes, get nothing.

I’ve been writing about money for more than 35 years, and I’ve watched a lot of companies build incentives that work against the customer. Usually you have to dig to find them. This one is written down in a federal payment methodology document.

How a denial turns into a payday

The program is called the Wasteful and Inappropriate Service Reduction model, or WISeR. It launched Jan. 1, 2026, and runs through 2031.

It applies only to Original Medicare, not Medicare Advantage, and only in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington.

If you live in one of those states and your doctor wants to perform one of a short list of outpatient procedures, a private contractor now has to approve it first. We covered the setup when it was announced in “17 Services That Medicare Wants People to Stop Using.”

Here’s the part that got less attention...