CMS Launches WISeR Model to Cut Overuse in Medicare with AI-Driven Prior Authorization

The Centers for Medicare and Medicaid Services (CMS) has launched the Wasteful and Inappropriate Service Reduction (WISeR) Model aiming to reduce the use of 17 types of healthcare services deemed prone to overuse, waste, fraud, or abuse within Original Medicare. This model, starting in 2026 and running through 2031, involves health technology companies using advanced tools, including artificial intelligence, to assess the medical necessity of services and conduct prior authorization on behalf of payers. These companies will share savings generated from reducing inappropriate care, with payouts adjusted based on performance metrics and provider experience. WISeR will be piloted in six states — New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington — and imposes the choice on providers between pre-service prior authorization or post-service prepayment review for these services.

Although the services targeted under WISeR have demonstrated medical necessity through CMS’s national and local coverage determinations and meet FDA safety and effectiveness standards, the initiative addresses concern over their frequent overutilization or risk profile. CMS has embedded safeguards to prevent barriers to care, including unlimited resubmissions for authorization requests and peer-to-peer clinical review options to contest non-affirmation decisions. However, the delegation of prior authorization to private entities incentivized by savings and the reliance on AI present risks of increased denials and administrative burdens, especially given precedents in Medicare Advantage plans.

WISeR represents a policy shift towards integrating technology-driven utilization management within traditional fee-for-service Medicare, historically cautious about prior authorization due to administrative complexity and potential care delays. The program’s success will hinge on the effectiveness and integrity of AI tools, the oversight quality of the external contractors, and the balance CMS strikes between cost control and access to medically necessary services. This approach could set a precedent for broader centralized cost containment strategies if appropriately managed.

Stakeholders such as providers and patient advocates must monitor implementation closely given the increased administrative requirements and potential for impact on patient care, particularly for those with chronic or complex conditions. The program’s performance will warrant scrutiny on whether it achieves cost savings without adversely affecting care quality or access. Ultimately, WISeR underscores evolving utilization management in Medicare and raises critical questions about the role of AI and private contractors in claims review and prior authorization processes.