The Centers for Medicare & Medicaid Services announced June 27 the rollout of a 6-year technology-enabled prior authorization program pilot called the Wasteful and Inappropriate Service Reduction Model that will partner with third-party entities to implement AI-enhanced prior authorization for specified services in traditional fee-for-service Medicare.
CMS launched the WISeR Model to test enhanced technologies, including artificial intelligence, in expediting prior authorization processes for select items and services vulnerable to fraud, waste, and abuse. The model targets specific services including skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy for knee osteoarthritis. Companies selected to participate will operate in assigned geographic regions and must have clinicians with appropriate expertise to conduct medical reviews. Under the regionally based model, participating providers can choose to submit prior authorization requests for selected items and services or subject their post-service claims to pre-payment medical review. The model excludes inpatient-only services, emergency services, and services that would pose a substantial risk to patients if delayed.
The WISeR Model operates on a performance-based payment structure where participating companies receive payments based on their ability to reduce unnecessary or non-covered services and lower spending in Original Medicare. Participants' payments will be adjusted based on their performance against established quality and process measures that evaluate their ability to support faster decision-making and improve provider, supplier and beneficiary experience. While technology will support the review process, final decisions that a request does not meet Medicare coverage requirements will be made by licensed clinicians, not machines. The model does not change Medicare coverage or payment criteria, and beneficiaries retain the freedom to seek care from their provider or supplier of choice.
"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."
"Low-value services, such as those of focus in WISeR, offer patients minimal benefit and, in some cases, can result in physical harm and psychological stress," said Abe Sutton, Director of the CMS Innovation Center. "They also increase patient costs, while inflating health care spending."
Prior authorization is a process where healthcare providers must obtain approval from insurance companies before providing certain medical services or procedures. Traditional prior authorization processes have been criticized for creating administrative burdens and delays in patient care. The WISeR Model represents CMS's attempt to modernize this process using artificial intelligence and enhanced technologies while maintaining clinical oversight through licensed healthcare professionals.
This pilot program specifically targets high-risk services that have been identified as particularly vulnerable to fraud, waste, and abuse in Original Medicare. The focus on skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy for knee osteoarthritis suggests these areas have shown patterns of inappropriate utilization. By testing AI-enhanced prior authorization in these specific service areas, CMS aims to create a model that could potentially be expanded to other vulnerable services if successful. The regional approach allows for controlled testing while the performance-based payment structure incentivizes participating companies to genuinely reduce waste rather than simply create additional administrative barriers.
The WISeR Model represents a shift toward technology-enabled healthcare oversight in Medicare, specifically targeting services with documented patterns of waste and inappropriate use. Healthcare providers in pilot regions will need to adapt to new prior authorization processes while beneficiaries should experience improved protection from unnecessary procedures. The success of this 6-year pilot could reshape how Medicare approaches fraud prevention and utilization management across the entire program.
Only licensed clinicians will make final determinations, not artificial intelligence algorithms.
Yes, beneficiaries will be informed of any denial decisions and will retain the right to appeal.
No, participation is limited to providers within the geographic areas assigned to selected review entities.
Providers may face workflow changes initially but are expected to benefit from faster decision-making over time.
CMS requires all participating vendors to maintain clinician oversight and adhere to strict quality review protocols.