Inside the WISeR Model: CMS’s First Tech-Only Innovation Initiative

Jul 7

CMS is launching a first-of-its-kind model that puts technology companies at the center of Medicare’s prior authorization process with the Wasteful and Inappropriate Service Reduction (WISeR) Model. The WISeR Model aims to focus health care spending on services that improve patient well-being, apply lessons learned from commercial payer prior authorization processes that may be faster, easier, and more accurate, increase transparency of existing Medicare coverage policy, and de-incentivize and reduce the use of medically unnecessary care.

Quick Summary

The model seeks qualified technology companies as model participants to implement and streamline the prior authorization process for select items and services that may be considered fraudulent, wasteful, or of low value to beneficiaries in Original Medicare.

Participants (tech companies) are expected to apply their technology to help medical reviewers assess a set of items and services that may pose concerns related to patient safety if delivered inappropriately, have existing publicly available coverage criteria, and may involve prior reports of fraud, waste, and abuse.

Participants are rewarded for the effectiveness of their technology in reducing spending on medically unnecessary or non-covered services. Participants receive a percentage of the reduction in savings that can be attributed to their reduction of wasteful or inappropriate care. Example selected services (chosen based on CMS’ identification of services with limited clinical benefit for some patients and vulnerability to fraud) include skin and tissue substitutes, electrical nerve stimulation, and knee arthroscopy for knee osteoarthritis.

The selected MAC jurisdictions for WISeR are JH, JL, JF, and J15, and the selected states are NJ (JL/Novitas), OH (J15/CGS), OK and TX (JH/Novitas), and AZ and WA (JF/Noridian). CMS plans to accept one model participant per selected MAC jurisdiction for a total of 4 participants.

Why It Matters

This is the first CMMI model in which technology innovators will be the only model participants and the first model that the new administration has released. The Model enables private sector AI integration into Medicare.

The Model development cycle was quick, and CMS provided a short application timeline, which suggests that there is a rush by the Administration to stand this model up, and as a result, there may be some major operational obstacles when this launches in 2026. Given how quickly this model has moved, we’re curious what kind of conversations CMS has had with the MACs involved. Potential risks include heightened administrative burden for providers and a further deterioration of the payer-provider relationship.

Food for Thought

As the model moves forward, several important questions about implementation remain unanswered particularly around clinician qualifications:

Who qualifies as a “relevant clinician” under the model?

Must the reviewers be physicians, or could advanced practice providers (APPs), such as nurse practitioners or physician assistants, fulfill this role?

What credentials or experience will be required for clinicians making determinations using the AI-supported tools?

Clarifying these points will be essential to understanding the model’s operational requirements and ensuring clinical integrity throughout the prior authorization process.

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