How Medicare’s AI “Bounty-Hunter” Setup Mirrors ACC’s Medical Gatekeeper Problem

Introduction

I’ve just been sent a troubling story from the US that hits too close to home (Thank you, Wayne). America's Medicare is rolling out the WISeR Model (“Wasteful and Inappropriate Service Reduction”)—an AI-driven prior-authorization experiment starting January 1, 2026 in six states. It’s being sold as a way to trim waste and speed up decisions, but the catch is this: tech companies get paid a share of every claim they help reject—literally rewarded for saying “no” to care. https://futurism.com/medicare-pay-ai-companies

Sound familiar? You bet it does. Begin by reading this article: https://www.garymoller.com/post/acc-vaccine-injury-costs-where-the-money-really-goes-and-how-to-fix-it

The Mirror Image of ACC's Problem

1. The perverse incentive is the same

In New Zealand, ACC has long paid medical specialists, assessors and case-managers for their input into claims—even if that input tips the decision towards rejection. Similarly, under WISeR, tech firms receive payment based on savings from denied claims. Both systems reward gatekeepers for denial, not care.

2. Clinical authority is the smoke screen

WISeR promises human clinicians will sign off on AI refusals—but critics point out private insurers have done the same and still deny en masse. And in ACC’s case, they handpick “independent” assessors who are more likely to give the decisions ACC wants. Don't think it'd coming here? Think again: https://www.nzherald.co.nz/nz/acc-bonus-pay-for-claimant-cull/DAC2X5NJIBBGKUR4TTTBAIFEGM/

3. Patients lose either way

Layered decision-making, fragmentation of their evidence, delays—all these strategies serve to shut down genuine claims without the public noticing. That's exactly what happens when algorithmic or specialist gatekeepers are incentivised to minimise pay-outs.

Glimpses of the Pattern

• Under WISeR, 17 specific services deemed over-used—from steroid joint injections to spinal procedures—will require prior authorisation or else face rejection or delay.

• Medicare insists there are safeguards: emergency care isn’t affected, clinicians will sign off, and the services targeted already fall under national coverage guidelines.

• But watchdogs argue that human sign-off doesn’t prevent abuse. Algorithms have been shown to reject care due to small data quirks—typos or biases.

• On the ACC side, it’s not new. A decade ago, cabinet minister Judith Collins admitted ACC staff received bonus pay for closing long-term claims. Staff were rewarded for “kicking claimants off the books”—and ACC would lose pay if they didn’t.

A Global Pattern in Gate-Keeping

Here’s what ties these systems together:

• Incentives shape behaviour. Whether tech firms or specialists, gatekeepers are rewarded for denying access, not helping people.

• Authority obscures accountability. Calling decisions “clinical” or “AI-supported” hides the financial drivers.

• Outcomes suffer. Genuine need falls by the wayside while system defenders profit.

What Can Be Done

1. Expose the incentives. Declare them clearly. If a system rewards denials, the public should know that upfront.

2. Demand transparency. WISeR needs public access to its AI’s training, validation and performance data. Providers should monitor systemic error trends.

3. Require meaningful human control. Human clinicians should override denials with no penalty to providers or firms.

4. Rethink ACC’s reliance on “specialist” assessors. Move towards genuinely independent reviews, clearer causation tests and more compassionate thresholds for treatment-injury claims. https://nzmj.org.nz/media/pages/journal/vol-137-no-1589/acc-and-treatment-injuries-is-it-time-to-rethink-injury-causation/0bbd91bf74-1706653510/6353.pdf

5. Establish a Charitable Trust that pays for independent medical reports and legal repsentation for ACC claimaints.

Concluding Words

This isn’t just an ACC problem, or just a Medicare problem. It’s a global symptom of systems that reward those who block access to care—not those who empower recovery. ACC’s model and Medicare’s WISeR pilot are two sides of the same coin—systemic structures turning financial incentives into human harm.

People in pain deserve healing, not hoops. Institutions must serve people, not shield their own balance sheets.