{"id":9842,"date":"2025-08-29T10:29:32","date_gmt":"2025-08-29T15:29:32","guid":{"rendered":"https:\/\/www.appliedpolicy.com\/staging\/7403\/?p=9842"},"modified":"2025-09-09T08:54:02","modified_gmt":"2025-09-09T13:54:02","slug":"wiser-model-signals-changes-in-cmss-approach-to-prior-authorization","status":"publish","type":"post","link":"https:\/\/www.appliedpolicy.com\/staging\/7403\/wiser-model-signals-changes-in-cmss-approach-to-prior-authorization\/","title":{"rendered":"WISeR Model Signals Changes in CMS\u2019s Approach to Prior Authorization"},"content":{"rendered":"

With its June announcement<\/a> of the Wasteful and Inappropriate Services Reduction (WISeR) Model, the Centers for Medicare & Medicaid Services (CMS) signaled a new willingness to apply prior authorization in fee-for-service Medicare. Stakeholders are asking whether the model, which represents an evolution in the agency’s oversight of Original Medicare, also raises questions about how CMS may employ utilization management in the future.<\/p>\n

Background<\/strong><\/p>\n

CMS has framed WISeR as a safeguard for the integrity of the Medicare program, saying<\/a> it will “protect people with Original Medicare by crushing fraud, waste, and abuse.” The program\u2019s request for applications (RFA<\/a>), which was released on June 26, cites research<\/a> estimating that as much as one-quarter of U.S. health care spending is unnecessary, and the Medicare Payment Advisory Commission has estimated<\/a> that Medicare spent up to $5.8 billion on low-value services in 2022. By requiring prior authorization or prepayment review for select procedures, CMS aims to steer beneficiaries away from low-value care, safeguard patients from avoidable harm, and reduce costs to the Medicare Trust Fund.<\/p>\n

The Model<\/strong><\/p>\n

WISeR will begin in January 2026 and run for six years, divided into two three-year agreement periods. Initially, it will operate in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington, spanning four Medicare Administrative Contractor jurisdictions<\/a>: JH, JL, JF, and J15.<\/p>\n

Under WISeR, contracted vendors\u2014technology companies with experience managing prior authorization programs for other payers, including Medicare Advantage (MA)\u2014will conduct prior authorizations and prepayment reviews for a defined set of services that CMS has identified as vulnerable to misuse. These include skin substitute grafts for diabetic foot and venous leg ulcers, implantation of electrical and sacral nerve stimulators, deep brain stimulators, certain epidural steroid injections, knee arthroscopy for osteoarthritis, and vertebral augmentation procedures (find the full list below). Although determinations of coverage\u2014either “affirmations” or “non-affirmations”\u2014will leverage enhanced technologies such as artificial intelligence (AI) and machine learning, CMS has emphasized<\/a> that non-affirmations must be reviewed by a licensed medical doctor or other qualified clinician and “cannot be performed solely by technology.”<\/p>\n

While CMS characterizes WISeR as “voluntary”, it is important to note that the voluntary element applies to technology vendors, whom the RFA defines as the model’s “participants,” rather than to healthcare providers. As outlined in the RFA, the technology-enabled process will be available to all Medicare-enrolled providers and suppliers furnishing the included items and services in the selected regions. These providers will have the option to submit a prior authorization request. However, should they choose not to, their claims for services covered under the model will be subject to medical review by the model participant during prepayment processing. In practice, this means that although providers are not required to submit prior authorization requests, payment for the designated services cannot be secured without either prior authorization approval or successful passage through prepayment review.<\/p>\n

CMS will not pay vendors selected to participate in WISeR a flat administrative fee. Instead, the agency has established a contingency-based structure that ties compensation to the Medicare savings generated when designated services are not affirmed and ultimately not paid. CMS will calculate these savings using historical average payments for each service type, and vendor payments will be adjusted based on performance measures such as the timeliness and accuracy of their determinations. This approach echoes the Recovery Audit Contractor (RAC) program, which Applied Policy has previously discussed<\/a>. However, while RAC rewards vendors for identifying past overpayments, in WISeR, incentives are applied prospectively for claims that are never filed.<\/p>\n

According to a CMS FAQ, the WISeR program will give providers and suppliers “unlimited opportunities” to resubmit an individual request, and “a non-affirmed decision does not prevent the provider\/supplier from delivering the service and submitting a claim.” Only after a service is furnished and a Medicare Administrative Contractor denies payment can the provider pursue an appeal before a separate adjudicator.<\/p>\n

Stakeholder Reactions<\/strong><\/p>\n

Few dispute that low-value care remains a costly problem in the U.S. health system. A recent New York Times report<\/a> on Medicare\u2019s use of skin substitute grafts described it as an area where \u201ccosts have soared despite uncertain benefits,\u201d and investigations by the Office of Inspector General have identified improper payments for neurostimulation implants<\/a> and epidural steroid injections<\/a>.<\/p>\n

There is less agreement, however, on whether WISeR is the right mechanism to address the problem. Reaction to the model has been mixed, reflecting both optimism about its potential to curb waste and concerns about its implications for patients and providers. Supporters note that WISeR targets a narrow set of services associated with overuse or fraud and view it as a way of protecting patients from unnecessary and potentially harmful interventions. Consistent with the administration\u2019s embrace of AI, CMS has emphasized that the model could improve accuracy and consistency in coverage decisions by leveraging new technologies.<\/p>\n

Commentators have also suggested that, if successful, WISeR could demonstrate how automation and clinical oversight might streamline prior authorization across the broader health system. Brian Miller, MD, non-resident fellow at the American Enterprise Institute and practicing physician, observed<\/a> that “[doctors] sometimes get things wrong\u2014and having an additional check for some items and services is important.” America\u2019s Physician Groups has expressed support<\/a> for CMS\u2019s effort to test prior authorization in Original Medicare, emphasizing that the model could provide a platform for reducing costs that would otherwise be \u201cborne by taxpayers and Medicare beneficiaries.\u201d<\/p>\n

However, several medical organizations have voiced strong objections. The American College of Physicians, which represents 161,000 internal medicine physicians, subspecialists, and medical students, contends<\/a> that “WISeR would add another layer of complexity to an already overburdened process.” The group also cautioned that “integrating AI into prior authorization introduces additional challenges, including potential algorithmic bias, opaque decision-making processes, and insufficient accountability.” The American Medical Association has cautioned<\/a> that “payment structures must be designed to avoid perverse incentives that reward denials over appropriate approvals.” In urging CMS to reconsider the implementation of the WISeR model, a coalition of 23 surgical societies argued<\/a> that the model “represents a substantial reversal of progress toward prioritizing patients over paperwork.”<\/p>\n

For the Medical Group Management Association, the timing of WISeR highlighted what it viewed as a contradiction. The group noted that CMS released the WISeR RFA within a week of Health and Human Services Secretary Robert F. Kennedy Jr. and CMS Administrator Mehmet Oz announcing<\/a> that they had secured a pledge<\/a> from health insurers to “fix broken prior authorization” processes for Medicare Advantage, Medicaid Managed Care, and the Health Insurance Marketplace. However, CMS contends that WISeR is consistent with the pledge, emphasizing that the model is designed to enhance transparency and communication around authorization decisions and appeals and ensure that medical professionals review all clinical denials.<\/p>\n

Alexandria Ocasio-Cortez (D-NY) has led a small coalition of Democratic House members asking CMS to halt implementation of the program, arguing in a July letter<\/a> that WISeR would make prior authorization effectively mandatory for providers in fee-for-service Medicare and create financial incentives for vendors to deny care.<\/p>\n

Conclusion<\/strong><\/p>\n

Ultimately, the conversation about the WISeR model reflects a fundamental tension in U.S. health care policy: how to eliminate waste and fraud in Medicare without erecting barriers that limit access to necessary care and frustrate clinicians. As CMS moves forward, the WISeR model will serve as a benchmark for how far the agency is willing to extend utilization management into Traditional Medicare. The application period for vendors closed in July, setting the stage for the program\u2019s January 2026 launch. Whether WISeR ultimately succeeds in striking the right balance between safeguarding taxpayer dollars and preserving timely access to care will depend not only on the performance of its technology vendors, but also on CMS\u2019s responsiveness to provider and patient concerns. The outcome of this demonstration could shape the future of prior authorization in Medicare for years to come.<\/p>\n

******************<\/p>\n

Procedures covered under WISeR:<\/strong><\/p>\n