CMS Introduces WISeR Model for Medicare Prior Authorization

The Centers for Medicare & Medicaid Services (CMS) introduced the Wasteful and Inappropriate Service Reduction (WISeR) Model in January. This initiative leverages AI-assisted prior authorization for specific procedures within traditional Medicare, aiming to reduce costs and streamline administrative processes for healthcare providers and suppliers.

Piloted in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington, WISeR mandates that physicians obtain prior approval for a select set of procedures. AI technology, managed by third-party contractors working with CMS, handles initial reviews of these requests. A licensed clinician must approve any denials to ensure medical oversight, CMS explained.

WISeR seeks to address issues of overuse and potential fraud by determining if AI can enhance the efficiency and consistency of authorization processes. In Texas, initial approval rates are 62%, rising to 84% post-physician review, according to technology provider Cohere Health. Brian Covino from Cohere Health emphasized that most approved requests receive same-day responses. Conversely, a study by KFF highlighted a 92% approval rate for Medicare Advantage prior authorizations nationwide in 2024.

With the program still in its infancy, discrepancies exist compared to Medicare Advantage. Abe Sutton from the CMS Innovation Center noted that variations in approval rates are expected as WISeR evolves and integrates further.

The introduction of pre-approval procedures has posed challenges, especially for patients unaccustomed to such requirements. An Oklahoma case highlighted significant delays for a spinal epidural due to the new model's review process. In Ohio, technical difficulties with the Innovaccer portal affected timely authorizations, extending beyond the intended three-day timeframe for non-urgent procedures. Similarly, Arizona faced payment delays from unassigned authorization tracking numbers, as reported by Washington Post Intelligence.

CMS remains committed to allocating funds only for clinically appropriate care. Chris Krepich, a CMS spokesperson, assured that AI decisions are supervised by clinicians, and subpar vendor performance will lead to corrective actions.

Starting in July, CMS plans a "gold card" exemption for physicians with over a 90% approval rate, allowing them to bypass the pre-submission process. The WISeR initiative, running until 2031 across six states, intends to cover about 207,500 beneficiaries in its first year, according to KFF data.

The program’s payment model, which links vendor compensation to cost savings from service denials, has raised concerns from advocacy groups. CMS asserts that vendor payments also consider accuracy and quality indicators, ensuring a balanced approach to service provision and fiscal responsibility.