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The Centers for Medicare & Medicaid Services (CMS) announced a new initiative on November 23, 2025, launching the Wasteful and Inappropriate Service Reduction (WISeR) model in Arizona, new Jersey, Ohio, Oklahoma, texas, and Washington, beginning January 1, 2026. The program seeks to refine prior authorization processes for customary fee-for-service Medicare using artificial intelligence (AI) and enhanced technologies to reduce payments for services deemed “low value.”
A Shift in Traditional Medicare Coverage
For decades, traditional Medicare has largely avoided extensive prior authorization requirements, a common practice in Medicare Advantage plans. This new model represents a critically importent departure, signaling a broader effort to control healthcare costs and improve efficiency. “This initiative marks a significant change,” noted one industry observer, highlighting the potential impact.
How WISeR Aims to Generate Savings
The WISeR Model will operate by requiring prior authorization for certain services in the selected states. Model participants – healthcare organizations contracted by CMS – will review requests and determine whether to approve or deny them. Savings will be calculated by comparing current expenditures to past regional claims data. Specifically, savings will be resolute by multiplying the number of denied requests by the average historical payment for that service.
However, the payment structure includes safeguards. CMS will withhold payments for denials that are resubmitted and affirmed within 120 days, and possibly for up to a year if the authorization is resubmitted. Furthermore, if a provider successfully appeals a denial, any associated payment will be “clawed back” from the model participant.Payments will also be adjusted annually based on quality metrics.
Providers and suppliers will have the option to submit prior authorization requests directly to the model participant or through their existing Medicare Administrative Contractor (MAC).Those who choose not to submit a request will face a post-service, pre-payment review. Providers can appeal denied requests to the MAC, and ultimately through the standard Medicare claim appeal process. CMS indicated that providers with a strong record of compliance may eventually qualify for a “gold card” exemption from the WISeR review process.
Data Security and Sharing: A Critical Component
Data collection and sharing are central to evaluating the WISeR Model’s effectiveness. CMS will establish data sharing policies governing facts exchange between participants, MACs, providers, and suppliers. Recognizing the sensitivity of patient data, participants will be required to adhere to stringent security protocols, including:
- Maintaining access to the federal Risk and Authorization Management Program workflows.
- Adhering to the Federal Information Security Management Act regulations.
- Complying with the CMS Information Systems Security & Privacy Policy.
- Implementing the CMS Acceptable Risk Safeguards.
- Following the CMS Authority to Operate guidelines.
- Executing Business Associate Agreements with MACs.
CMS also plans to provide providers and suppliers with access to certain data from model participants and MACs. A visual depiction of the data sharing framework would be beneficial here.
Industry Concerns and the Role of AI
The expansion of prior authorization,particularly the integration of AI,has sparked debate within the healthcare industry. Concerns have been raised about the potential for AI to inappropriately delay or deny necessary care, echoing lawsuits filed against Medicare Advantage plans. Though, others argue that AI-driven prior authorization could streamline processes and reduce costs.CMS has stated its commitment to monitoring the model’s performance to prevent abuse.
The debate highlights a broader tension between cost containment and access to care. As one analyst noted, “The success of the WISeR model will hinge on finding the right balance between reducing wasteful spending and ensuring patients receive the treatments they need.”
Looking Ahead: A Five-Year Pilot
The WISeR Model is currently slated as a five-year pilot program, running from January 1, 2026, to December 31, 2031. the results of this pilot will be crucial in informing future CMS models and potentially shaping the future of prior authorization in traditional Medicare. The model’s performance, both in terms of cost savings and patient outcomes, will be closely watched by stakeholders across the healthcare landscape.
