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On June 27, the Centers for Medicare & Medicaid Services (CMS) announced a new model for expediting prior authorization and reducing wasteful spending for Medicare, which builds on other prior authorization changes announced by the U.S. Department of Health and Human Services.
The Wasteful and Inappropriate Service Reduction (WISeR) Model is a voluntary program that will harness enhanced technologies such as artificial intelligence and machine learning to expedite prior authorization processes for items and services found to be vulnerable to fraud or inappropriate use. Although technology will be used in the review process, licensed clinicians will make all final decisions on whether a request for one of the selected services does not meet Medicare coverage requirements.
WISeR will run for six performance years from Jan. 1, 2026, to Dec. 31, 2031. The WISeR model will not alter Medicare coverage or payment criteria. Those enrolled in Medicare Advantage will not be impacted.
Beginning January 1, 2026, the prior authorization process under WISeR will be implemented in select states, in select MAC jurisdictions, and on certain items and services affiliated with specific NCDs or LCDs.
Partner companies selected to participate will operate in assigned geographic regions and will be required to have clinicians with sufficient expertise to conduct medical reviews and validate coverage determinations. They will receive payments based on their ability to reduce unnecessary or noncovered services and to lower Medicare spending.
CMS has issued a Request for Applications to companies interested in participating. Applications are due by July 25.
“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,” said CMS Administrator Mehmet Oz, M.D., said in a press release.
Sources:
https://www.cms.gov/priorities/innovation/innovation-models/wiser
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