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BSHeadline Over Filing

Paid a share of the care they avert

He said his understanding was no. Medicare's own page for the program says they are paid a percentage of the care their reviews avert.

“Asked at a September 16 Senate hearing whether the private contractors in WISeR, Medicare's AI-assisted prior authorization pilot, make more money if they deny care, CMS deputy administrator Chris Klomp answered 'My understanding is no' and said inappropriate denials carry significant financial penalties.”

Chris Klomp, CMS deputy administrator and nominee for HHS deputy secretary (Senate HELP hearing), 16 September 2026

28 receipts2 support3 refute23 context

Issue 2626 September 20263 min
A hand holds a red stamp reading DENIED over a document, with a gavel and a small stack of coins on the desk.
AI illustration

CMS's own WISeR page says participants receive a percentage of the expenditures associated with averted care as a result of their reviews. Ars Technica, citing CMS participant guidance, reports that means 25 percent of the regional benchmark cost for each denied request.

The twist

the penalty exists, but on Ars Technica's reading of the documents it is small. A contractor with a quality score between 60 and 84 percent keeps 95 percent of that 25 percent, and one below 60 percent keeps 90 percent. Denials that are appealed and overturned are not paid.

25 percentshare of the regional benchmark cost CMS pays a WISeR contractor for each denied request
3,233prior authorization requests Virtix denied in Washington state out of 6,096 reviewed
95 percentshare of its averted-cost payment a contractor keeps with a quality score between 60 and 84 percent
83 dayslongest pending WISeR decision in the released documents

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The trick has a name

We call it Headline Over Filing: the document underneath says something else. You'll see it again. Learn to spot it →

Say this in tomorrow's meeting“Medicare's own WISeR page says the AI prior authorization contractors get a percentage of the spending their reviews avert. The official asked if they earn more by denying care said his understanding was no.”

Receipts

  1. Context web.archive.org: Do the contractors in the model—who are the private companies conducting the prior authorization assessments—make more money if they deny care? Just yes or no?
  2. Context arstechnica.com: In January, the Trump administration rolled out a pilot program that uses artificial intelligence to authorize or deny certain types of care for patients with Medicare
  3. Supports arstechnica.com: “My understanding is no,” Klomp replied.
  4. Supports web.archive.org: My understanding is when they deny care, and if they do so inappropriately, there are significant financial penalties and that CMMI is carefully watching their performance and has the ability to terminate.
  5. Refutes cms.gov: Model participants receive a percentage of the expenditures associated with averted wasteful, inappropriate care as a result of their reviews.
  6. Context cms.gov: That percentage is adjusted based on the participant’s performance on measures related to the process, including provider experience.
  7. Context cms.gov: The Wasteful and Inappropriate Service Reduction (WISeR) Model helps protect American taxpayers by leveraging enhanced technologies, such as Artificial Intelligence (AI) and Machine Learning (ML), along with human clinical review, to ensure timely and appropriate Medicare payment for select items and services.
  8. Context cms.gov: All recommendations for non-payment are determined by appropriately licensed clinicians who will apply standardized, transparent and evidence-based procedures to their review.
  9. Refutes arstechnica.com: CMS documents written as a guide for WISeR participants explain further that for every denied request, CMS will determine what the regional benchmark cost for that care would have been and then pay the company 25 percent.
  10. Context web.archive.org: And we also know that the CMS Office of the Actuary literally said in a memo
  11. Refutes web.archive.org: model participants will have an incentive to deny as many claims as possible.
  12. Context arstechnica.com: If a company’s score falls between 84 percent and 60 percent, it will be paid 95 percent of the 25 percent of averted costs
  13. Context arstechnica.com: If it scores below 60 percent—a failing grade by school standards—it will get 90 percent.
  14. Context arstechnica.com: Companies won’t be paid if an authorization denial is appealed and overturned, but data suggests few people go through the appeal process.
  15. Context arstechnica.com: According to a weekly report on March 30, Virtix had reviewed 6,096 pre-authorization requests. It approved 2,863 of them, denying 3,233 (53 percent).
  16. Context arstechnica.com: the WISeR program uses long-established [National Coverage Determinations] and [Local Coverage Determinations] set by CMS, not by Virtix Health, to evaluate the medical appropriateness of each requested procedure.
  17. Context vox.com: One review took 83 days when the model was supposed to make a decision within 72 hours.
  18. Context web.archive.org: at a Senate Committee on Health, Education, Labor, and Pensions (HELP) hearing to consider Trump’s latest slate of nominees for the Department of Health and Human Services (HHS)
  19. Context arstechnica.com: Chris Klomp, deputy administrator of the Centers for Medicare and Medicaid and US President Donald Trump's nominee to be deputy secretary of Health and Human Services (HHS)
  20. Context web.archive.org: it is not my center that was responsible for developing the WISeR model
  21. Context web.archive.org: they will be producing a report or a report card, something shortly that will show an accounting by vendor in these trial markets
  22. Context cms.gov: WISeR will run for six performance years from January 1, 2026 to December 31, 2031 in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington.
  23. Context arstechnica.com: Those reports were largely confirmed earlier this month when the Electronic Frontier Foundation released a tranche of federal documents about the program, called WISeR, that the group obtained amid litigation.
  24. Context arstechnica.com: A company that earns an AQS score of between 100 percent and 85 percent will be paid all 25 percent of the “averted” costs from denied claims.
  25. Context arstechnica.com: In a statement to Ars Technica, Virtix confirmed it was on a CAP but said it has since “reduced its average turnaround time for prior authorization to 1.18 days
  26. Context arstechnica.com: Virtix said the CAP ended on August 14.
  27. Context arstechnica.com: Virtix encouraged providers to consider resubmitting authorization requests and ask for peer-to-peer discussion about denials.
  28. Context arstechnica.com: It was revealed in June that Virtix was put on a Corrective Action Plan (CAP) by the Centers for Medicare & Medicaid Services (CMS)

Open the Receipts Pack → What each source proves, every figure traced, and what would change our verdict.

Checked by AI at the BS Killer desk · ruled 26 Sept 2026 · How we check →

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