CMMI ushers in new era with WISeR Model

Certain services covered under traditional Medicare will be subject to prior authorization under a new model from the Center for Medicare and Medicaid Innovation. The Wasteful and Inappropriate Service Reduction (WISeR) Model will debut on January 1, 2026, and affect Medicare providers and suppliers in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington. Prior authorization is a utilization management tool used by health plans, requiring approval before a treatment or service is provided. The model will run through December 31, 2031.

CMS is relying on authority granted to the Center for Medicare and Medicaid Innovation (CMMI) to implement the WISeR model. The Affordable Care Act added section 1115A to the Social Security Act, which grants the Secretary of the US Department of Health and Human Services broad authority to “test innovative payment and service delivery models to reduce program expenditures, while preserving or enhancing the quality of care furnished to Medicare, Medicaid and Children's Health Insurance Program beneficiaries.”

To date, CMMI has used this authority to improve the quality and coordination of care for beneficiaries. While the WISeR model aims to reduce unnecessary care and waste, it introduces  a new approach to improving quality of care and health outcomes by potentially restricting items and services Medicare beneficiaries receive. CMS states that:

The WISeR model’s theory of change is that the implementation of prior authorization and prepayment review for selected items and services, performed by a third party (leveraging enhanced technologies) operating under a set financial arrangement can facilitate the navigation of beneficiaries away from low-value and other wasteful services that are commonly subject to FWA [fraud, waste, and abuse] given that non-affirmation of payment for the planned service typically results in discussions between patients and providers for alternative pathways.

CMS stated in the Federal Register notice that “key areas contributing to wasteful spending include fraudulent or abusive billing practices, as well as the delivery of services that have little or no clinical benefit, or services in which the risk of harm from the service outweighs its potential benefit.” The Request for Applications cites to a MedPAC estimate that Original Medicare spent between US$1.9 to US$5.8 billion on low-value services in 2022. At the same time, CMS states that it “is sensitive to concerns that the implementation of additional processes to reduce rates of low-value, fraudulent or wasteful care in Original Medicare could be perceived as limitations on access to care.”

Model participants will be technology companies “that apply emerging technologies to clinical and claims processing solutions and have experience and expertise managing the prior authorization for other payers.” In designing the WISeR model, CMS looked to Medicare Advantage practices, stating that “CMS is exploring findings from MA plans regarding enhanced technologies to examine how to efficiently, accurately and appropriately ensure select services are provided and paid for based on clinical and evidence-based guidelines.”

Notably, model participants will receive a percentage of the cost savings attributed to the prior authorization review process in their region. The model will also test:

[T]he speed and accuracy of new tech-assisted decision-making; the ability of participants to help patients navigate away from low-value or potentially unsafe treatments and towards clinically appropriate higher-value care through education and support to providers and suppliers; a novel payment approach that is based on paying WISeR participants a share of averted expenses in lieu of the traditional acquisition-based approach; and potential alignment with Medicare Advantage in terms of standardization, predictability and transparency.

The Request for Applications (RFA) includes the items and services that will be subject to prior authorization under the model:

Table 1: Items and services planned for initial performance year (subject to change) *

Source: WISeR Model Request for Applications, Centers for Medicare and Medicaid Services (July 2025)

CMS is also considering implementing “gold carding,” which would exempt providers from prior authorization if they achieve a provisional affirmation threshold of 90 percent during periodic assessments. The RFA also states that “a human clinician with relevant clinical expertise for selected items and services must review every non-affirmation determination, although this requirement does not apply to affirmations.” Providers will also be permitted to resubmit a denied request for prior authorization.

CMS is implementing the WISeR model, and its expanded incorporation of prior authorization in traditional Medicare, at a time when prior authorization practices are facing increasing scrutiny. Just days before, CMS announced commitments from health insurers to “fix” prior authorization practices.

More information can be found on the WISeR website, the Requests for Application, and in the CMS press release.