CMS WISeR Model Launches Tech-Enabled Prior Authorization in Six States

The Centers for Medicare and Medicaid Services (CMS) announced the launch of the Wasteful and Inappropriate Service Reduction (WISeR) Model, set to begin on January 1, 2026, in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. This model targets the reduction of low-value and unnecessary medical services in traditional fee-for-service Medicare. It emphasizes the use of enhanced technologies, including artificial intelligence (AI), to improve prior authorization processes for specific Medicare-covered items and services such as skin substitutes and knee arthroscopy. The Model mandates approved technologies be used for prior authorization to verify medical necessity and clinical appropriateness, with CMS engaging private developers to license these technological tools. Participants in the model will receive a percentage of the Medicare program’s savings directly attributable to avoided unnecessary services, with payments contingent on denial outcomes not being appealed successfully within a 120-day window. CMS has instituted safeguards where payment to model participants can be clawed back if appeals overturn denials. Quality metrics will influence annual payment adjustments for participants. Providers can submit prior authorization requests either to the model participants or Medicare Administrative Contractors (MACs). If prior authorization is not sought, post-service, pre-payment reviews by the model participants or MACs may occur, requiring further documentation for certain services. Providers with a strong compliance record may earn exemptions from prior authorization under a “gold card” program. The initiative marks a substantial shift as traditional Medicare has typically not required prior authorization. CMS aims to collect and share data among stakeholders, implementing policies to protect patient data security and promote transparency. The announcement responds to concerns about AI-driven prior authorization possibly delaying care, balancing these with opportunities for cost reduction and avoidance of unnecessary services. The WISeR Model will be evaluated over a five-year period through December 31, 2031, and its outcomes will inform future CMS payment and utilization models. This program is significant for insurers and providers due to its potential to reshape prior authorization practices within traditional Medicare and the broader healthcare payment landscape.