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None the WISeR, Almanac, and Commure’s Latest Lawsuit
April 27, 2026
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Together with
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“Seniors shouldn’t have to worry whether AI decides if they get the care they need. It’s reckless.”
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Congressman Greg Landsman
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Washington state just delivered an unfortunate crash course on U.S. health policy after the model aimed at “Wasteful and Inappropriate Service Reduction” led straight to higher costs and fewer treatments for seniors.
Does Medicare need prior authorizations? CMS designed WISeR to find an answer by testing whether bringing AI-driven prior auths (which are already widespread among private payors in Medicare Advantage) to traditional Medicare could cut down on wasteful spending.
- The six-year pilot kicked off in six states on January 1st (AZ, NJ, OK, OH, TX, WA), targeting a list of 13 “low value” services with a high potential for fraud or waste – most notably orthopedic pain management procedures and skin substitutes.
Washington is already tapping out. Less than five months in, Senator Maria Cantwell (D-Wash.) had enough data to publish her new report on the “clear risks of AI in Medicare.”
- Drawing on a Washington State Hospital Association survey of 16 hospitals, the report found that procedures previously approved within days are now taking 4 to 8 weeks.
- CMS’ own WISeR standards call for responses to providers within 1 day for urgent care and 3 days for routine care, both of which are now clocking in at 15 to 20 days.
You get what you pay for. WISeR compensates third-party administrators for each claim they deny, under the assumption that these denials account for the reduction in wasteful spending.
- That obviously creates some adverse incentives, which the report eloquently framed up by saying the model “incentivizes WISeR contractors to weaponize AI-driven medical determinations not for the sake of efficiency… but to maximize profitability.”
- As a result, Washington hospitals have had to add staff and increase hours to manage the surge in prior auths – not a great formula for lowering the cost of care.
The report went straight to the top. At a Senate hearing last week, Senator Cantwell made her case directly to HHS Secretary RFK Jr., who said “that kind of delay is unacceptable.”
- He went on to say that prior auths are there to prevent the government from being “ripped off” by unethical providers and only applies to 5% of services in Medicare.
- That might be accurate, but it doesn’t mean they aren’t high-volume services. A separate KFF analysis found that 86% of the 1.1M Medicare beneficiaries that used at least one of the services on WISeR’s list in 2024 received a pain management service.
The Takeaway
Reducing waste in Medicare is a worthy goal, but so far it looks like the best way to make it happen probably isn’t by adding prior auths to the program that many seniors specifically chose to avoid them.
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- Almanac Lands $10M: Almanac Health closed a $10M seed round to advance its unified AI platform for clinical decision support. The startup was founded by physician-researcher Cyril Zakka, MD, whose work at Stanford introduced the first retrieval-augmented generation system for clinical medicine through one of the most-cited papers in NEJM AI. Almanac is initially focused on giving every clinician specialist reach, with decision support grounded in peer-reviewed evidence and built directly into their current workflows – without pharma ads.
- Utah Pushes Back on AI Doctors: Doctronic’s AI-powered prescription pilot was fun while it lasted. The Utah Medical Licensing Board called for an immediate suspension of the program after revealing that they only found out about it once it was already live. Doctronic apparently circumvented the Medical Board’s approval by going through Utah’s broader Office of AI Policy to secure permission for its AI to be able to renew 200+ medications. Doctronic’s co-founders shared their side of the story in a new blog post called “The Status Quo Is the Biggest Risk,” but if we had to guess the Medical Board probably thinks healthcare pilots that it’s never heard of are a bigger risk than the status quo.
- IKS Acquires TruBridge: IKS Health’s rumored acquisition of TruBridge proved yet again that where there’s smoke, there’s usually fire. IKS got the acquisition across the finish line by offering $26.25 per share for TruBridge, just above its previous close of $25 – although the stock has also nearly doubled in the last month. The press release was light on details, but TruBridge’s EHR and RCM services will reportedly strengthen IKS’ AI care enablement capabilities in the rural healthcare market, and the combined company will now support over 4k orgs and 150k clinicians.
- Commure Heads Back to Court: Commure just got served with a(nother) lawsuit alleging it engaged in “a brazen scheme to steal valuable trade secrets” from EHR developer Adaptamed in order to create a competing product. The suit also claims former Adaptamed customer WellCare Health provided unauthorized access to its EHRYourWay platform after Adaptamed denied Commure’s request to get a look at how the sausage was made “under the guise of potentially forming a partnership to shore up its own nascent Athelas Air EHR product.” General Catalyst’s digital health bellcow might be developing a pattern of IP theft litigation considering Canopy also recently accused it of exploiting a similar partnership.
- Zocalo Recibe Una Inversión: Zócalo Health closed $15M in Series A funding to scale its community care model for Hispanic populations. The fresh funds will help Zócalo grow its community-based workforce across the country and deepen its payor partnerships after already expanding from two regional health plans in 2024 to more than a dozen in 2025. The announcement touts 4x revenue growth on the back of high member retention and frequent monthly engagement thanks to having “promotoras de salud” embedded near the patients they serve.
- EndoTool IV Eliminates Severe Hypoglycemia: Data presented at the AACE Annual Meeting showed that Glooko’s EndoTool IV achieved an impressive 98% reduction in severe hypoglycemia across a 19-hospital system compared to its historical paper protocols. The evidence stemmed from a three-year retrospective analysis (Jan 2023 to Dec 2025) that included nearly 18k patients and over 362k blood glucose values. Severe hypoglycemia (blood glucose less than 40 mg/dl) incidence dropped to 0.005% using EndoTool’s patient-specific dosing to help standardize care, compared with 0.23% under paper protocols.
- Highgate + Brook: NY-based primary care provider Highgate Medical Group is teaming up with Brook Health to scale sustainable chronic care management to its patients’ daily lives. By combining AI-driven intelligence with dedicated clinical teams, Brook enables ongoing monitoring, personalized engagement, and earlier interventions that will support Highgate’s value-based care delivery without adding to its providers’ plates. Highgate is leveraging Brook’s infrastructure across remote patient monitoring, chronic care management, and advanced primary care management.
- RAPID Response: A new regulatory pathway could help bridge the gap between breakthrough device approvals and Medicare reimbursement. CMS joined forces with the FDA to launch the Regulatory Alignment for Predictable and Immediate Device program, which enables the agencies to work together so evidence generated for breakthrough FDA submissions can also be used to determine Medicare coverage. The RAPID program is expected to slash the delay between FDA market authorization and Medicare national coverage decisions.
- Picking the Right Antidepressant: A JAMA study showed that web-based clinical decision support can meaningfully improve antidepressant treatment. The trial randomized 520 adults with major depressive disorder across 47 sites (in Brazil, Canada, and the U.K.) to receive either an antidepressant selected using the PETRUSHKA tool (combines clinical and demographic predictors with patient preferences to personalize treatment) or usual care. Patients in the PETRUSHKA group were not only less likely to discontinue their medication at 8 weeks (17% vs. 27% under usual care), they also showed significantly greater improvement in PHQ-9 and GAD-7 scores at 24 weeks.
- ModMed Picks Up Bonsai: ModMed scooped up Bonsai Health to bolster its specialty-focused EHR with AI-driven patient engagement. Bonsai’s AI agents proactively scan patient histories for care gaps, match their needs against open schedule slots, and reach out via SMS and email to re-engage patients. That functionality will now be integrated with ModMed’s Klara patient engagement platform to complement its existing staff-led communication workflows and help automate practice growth across its network of nearly 50k providers.
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Abridge & Availity Redefine Payer-Provider Synergy
Abridge is teaming up with Availity to redefine payer-provider synergy at the point of conversation. The collaboration aligns Abridge’s evidence-aware intelligence with Availity’s real-time health information network to create a first-of-its-kind prior authorization experience, with a shared understanding between patients, providers, and payers. Find out how Abridge and Availity are extending conversational intelligence across the revenue cycle.
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Making the Case for AI
Healthcare organizations have a lot to gain from implementing AI that can enhance coding accuracy and quality metrics, but securing buy-in from leadership is a crucial first step. Check out Navina’s new guide by Dr. Michael S. Barr to see exactly how to demonstrate clear financial benefits, ROI potential, and alignment with organizational priorities to help ensure AI projects are successful.
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- State of Payor Enrollment and Credentialing: Over half of provider orgs are losing revenue due to credentialing delays – with many missing out on over $1M annually. Medallion’s new report unpacks the forces quietly undermining operational and financial performance, and how leaders across the industry are addressing them. Head over to the full report to get insights tailored to your role and org type.
- The Perfect Moment for Digital Health: With expanded support for remote care, digital health is positioned to play a central role in value-based models. Check out Withings’ latest overview to learn how connected technologies can help reduce preventable events while improving care quality and efficiency.
- Better Health Through Virtual-First Primary Care: For patients, positive health outcomes are driven by strong relationships built on trust with health systems and providers. Hear how Ovatient’s fully EHR-integrated, virtual-first care approach is helping primary care patients like Tito Santiago reach their care goals and build a stronger relationship with The MetroHealth System.
- Evidence, in the Flow of Care: Heidi brings trusted guidelines and peer-reviewed research directly into clinical workflows so decisions don’t stall care. Clinicians get clear, evidence-based answers without leaving the conversation. No ads, no limits, and no outside interests getting in the way of care. Find out how with Heidi Evidence.
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