Thursday, March 19, 2026

CMS launched the Wasteful and Inappropriate Service Reduction (WISeR) model on January 1, 2026, using AI and machine learning to screen prior authorization requests for Medicare fee-for-service in six states: Texas, Arizona, New Jersey, Ohio, Oklahoma, and Washington. The program targets high-scrutiny items like nerve stimulators, cervical fusions, and incontinence treatments. Human clinicians still review denials, but AI handles initial screening. The model runs through December 31, 2031.

Effective March 1, 2026, UnitedHealthcare expanded its diagnosis code policy to cover both outpatient and professional claims, with stricter Excludes 1 compliance requirements on mutually exclusive diagnosis codes. Separately, UHC dropped coverage for most remote patient monitoring (RPM) services starting January 2026 and will require prior authorization for outpatient chemotherapy via Optum CGP starting June 1, 2026. MA HMO/POS members now also need PCP referrals for specialists.

Candid Health — an AI-native RCM automation platform with $81.5M in total funding (Series C) and 178 employees — was named to the 2026 New York Digital Health 100 list. Candid serves 200+ healthcare organizations with ML-driven billing, coding, and claims processing. Their positioning: "revenue cycle automation" reducing cost-to-collect and increasing net collection rates.