CMS: ‘Model will help root out waste in original Medicare’ 

WASHINGTON – The Centers for Medicare & Medicaid Services (CMS) has announced the launch of the Wasteful and Inappropriate Service Reduction (WISeR) model, a new initiative aimed at improving and expediting the prior authorization process for original Medicare. This innovative model will partner with companies that specialize in enhanced technologies, including artificial intelligence (AI), to test more efficient ways to manage prior authorization. 

The WISeR model builds on a previous announcement by the U.S. Department of Health and Human Services (HHS) and CMS, in which major U.S. health insurers committed to six key reforms to streamline prior authorization across Medicare Advantage, Medicaid Managed Care, the Health Insurance Marketplace, and commercial health plans. 

“CMS is committed to crushing fraud, waste and abuse, and the WISeR Model will help root out waste in original Medicare,” said CMS Administrator Dr. Mehmet Oz. “Combining the speed of technology and the experienced clinicians, this new model helps bring Medicare into the 21st century by testing a streamlined prior authorization process, while protecting Medicare beneficiaries from being given unnecessary and often costly procedures.” 

The WISeR model will test whether AI-driven technologies can accelerate prior authorization for select Medicare services and items that are particularly vulnerable to fraud, waste, abuse, or inappropriate use. These include, but are not limited to: 

• Skin and tissue substitutes 
• Electrical nerve stimulator implants 
• Knee arthroscopy for knee osteoarthritis 

Excluded from the model are inpatient-only services, emergency services and any services that could pose a substantial risk to patients if delayed. 

Participating companies will operate in designated geographic regions and must employ clinicians with the appropriate expertise to conduct medical reviews and validate Medicare coverage determinations. While technology will assist in the review process, all final decisions regarding coverage will be made by licensed clinicians, not automated systems. 

Model participants will receive performance-based payments tied to their ability to reduce inappropriate utilization and lower Medicare spending. These payments will be adjusted based on performance against established quality and process measures, including: 

• Speed of decision-making for providers and suppliers 
• Provider, supplier and beneficiary satisfaction with the prior authorization process 

Under the WISeR model, providers and suppliers in participating regions can choose to submit prior authorization requests for selected services. If they do not, their claims will be subject to pre-payment medical review. Requests can be submitted either directly to model participants or through Medicare Administrative Contractors (MACs), who will forward them accordingly. 

CMS is also considering a future pathway that would allow providers and suppliers with strong compliance records to qualify for exemptions from WISeR review, reducing administrative burden and allowing greater focus on high-risk areas. 

The WISeR model does not apply to Medicare Advantage enrollees. 

CMS has issued a request for applications for companies interested in participating in the WISeR Model. 

To view the Model Overview fact sheet, visit: https://www.cms.gov/files/document/wiser-fact-sheet.pdf. 

For more information on the WISeR Model, visit: https://www.cms.gov/priorities/innovation/innovation-models/wiser.