The CMS WISeR Model
CMS Innovation Center's New Approach to Reducing Wasteful Care in Original Medicare
The Centers for Medicare and Medicaid Services (CMS) Innovation Center has launched the Wasteful and Inappropriate Service Reduction (WISeR) Model, a voluntary initiative designed to address one of the most persistent challenges in American health care: the delivery of medically unnecessary services that harm patients and waste taxpayer dollars. Set to run from January 1, 2026 through December 31, 2031, WISeR represents a novel approach that leverages enhanced technologies and private sector expertise to ensure that Medicare beneficiaries receive appropriate, evidence-based care.
Importantly, while “fraud and waste” has been used as a political shield to justify constitutional violations and to dismantle democratic institutions, it is an actual problem in Medicare and should be solved.
The Problem: Waste, Fraud, and Patient Harm
Health care waste represents a substantial burden on the American health care system, contributing to an estimated 25 percent of total health care spending in the United States. This waste takes many forms, but one particularly concerning category involves low-value services that lack clinical evidence of effectiveness, fail to align with patients’ specific health conditions or needs, and can lead to complications requiring additional unnecessary interventions.
Original Medicare’s (Medicare Part B) fee-for-service payment structure, which compensates health care providers based on the volume of services delivered, can inadvertently incentivize medically unnecessary treatments, diagnostic tests, and procedures. While the vast majority of health care providers prioritize patient health and safety, HHS OIG law enforcement cases have documented instances where some providers have abused Medicare by delivering expensive items or services to patients who do not meet coverage criteria and may not benefit from the intervention.
The consequences for patients can be significant. When inappropriate services are delivered, beneficiaries may experience financial harm through out-of-pocket costs, physical harm such as pain, bleeding, infection, or other complications, and psychological harm including anxiety over unnecessary tests and procedures. Specific areas of concern include skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy for knee osteoarthritis, all of which have been identified as vulnerable to inappropriate utilization.
The Proposed Solution: Technology-Enhanced Prior Authorization
WISeR introduces a targeted approach to reducing wasteful care by partnering with technology companies experienced in using enhanced technologies, including artificial intelligence and machine learning, to streamline and improve the medical necessity review process. Rather than creating new coverage policies, WISeR supports accurate and efficient review for compliance with existing coverage criteria established in statutes, regulations, National Coverage Determinations, and Local Coverage Determinations.
Now, we are in a world where barriers to care from prior authorizations are top of mind. The push back on this model is that this approach mimics prior authorizations.
The model is notable for being the first CMS Innovation Center initiative in which technology innovators serve as the sole model participants as opposed to medical practices. These participating companies bring expertise in applying enhanced technology to expedite approval processes while ensuring appropriate clinical expertise is incorporated into medical reviews. As a guardrail, all recommendations for non-payment must be determined by appropriately licensed clinicians who apply standardized, transparent, and evidence-based procedures, meaning that technology alone cannot deny coverage.
WISeR targets a narrow set of items and services that meet three criteria: they may pose patient safety concerns if delivered inappropriately, they have existing publicly available coverage criteria, and they have been subject to prior reports of fraud, waste, and abuse. The model explicitly excludes inpatient-only services, emergency services, and any services that would pose substantial risk to patients if delayed. CMS notes that beneficiaries retain full freedom to seek care from their Original Medicare provider or supplier of choice, and payment amounts for covered services remain unchanged.
Expected Outcomes: Benefits for Patients, Providers, and Taxpayers
For patients, WISeR aims to deliver fast, accurate determinations of whether certain services are reasonable and necessary, promoting safety and ensuring access to the most appropriate, effective care for their conditions. The model’s focus on evidence-based practices should help patients avoid unnecessary procedures that carry risks without commensurate benefits, redirecting care toward high-value interventions aligned with clinical guidelines. Hopefully, this results in actual reductions in unnecessary or low-value care and not more administrative burdens on necessary care.
Health care providers and suppliers who choose to submit prior authorization requests will receive advance confirmation that they will be paid for services, provided that applicable Medicare coverage and clinical documentation requirements are met and claims are billed correctly. The model aims to drive toward auto-approvals wherever possible, with most response times expected within 72 hours and many responses arriving much faster. Providers and suppliers with demonstrated records of compliance may eventually receive a limited exemption or gold card from the full WISeR review process, reducing administrative burden while allowing participants to focus resources on higher-risk providers.
From a fiscal perspective, model participants will only receive compensation if they reduce wasteful, inappropriate care, earning a percentage of savings associated with their reviews. This is a particularly innovative part of the model. This payment percentage will be adjusted based on performance measures related to process quality and provider experience.
Importantly, the payment methodology includes strong safeguards against inappropriate denials: CMS will audit participants for accuracy, audit results will affect quality scores and payment adjustments, and participants (the technology companies) with high inaccuracy rates may be terminated from the model. Participants bear responsibility for processing costs including unlimited resubmissions, and they receive payment only once per beneficiary regardless of resubmission volume, creating incentives for accurate initial determinations.
Administrative Details for Potential Participants
WISeR will operate in six states during its performance period: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington. Each state has been assigned to a specific participating technology company that will work within the corresponding Medicare Administrative Contractor jurisdiction. The six selected participants are Cohere Health (Texas), Genzeon Corporation (New Jersey), Humata Health (Oklahoma), Innovaccer Inc. (Ohio), Virtix Health LLC (Washington), and Zyter Inc. (Arizona).
Providers and suppliers in model regions have flexibility in how they engage with WISeR. Those who choose to submit prior authorization requests may do so either directly through the model participant’s electronic portal or through their Medicare Administrative Contractor, which will forward the request to the appropriate participant. WISeR participant electronic portals were scheduled to become operational by January 5, 2026, with the 72-hour turnaround time requirement applying to requests submitted through these portals for dates of service on or after January 15, 2026.
Until electronic portals are fully operational, providers and suppliers may submit prior authorization requests through their MAC, though processing may take longer than 72 hours due to additional forwarding steps. Alternatively, providers and suppliers may choose not to submit prior authorization requests at all. In such cases, claims for included services will be subject to post-service, pre-payment medical review to verify compliance with Medicare coverage, coding, and payment criteria before payment is issued.
The appeals process under WISeR maintains established protections for providers, suppliers, and beneficiaries. For non-affirmed prior authorization requests, where a future service is found not to meet Medicare requirements, providers and suppliers have unlimited opportunities to resubmit requests with additional documentation. A non-affirmed decision does not prevent providers from delivering the service and submitting a claim. When such claims are denied by the MAC, the denial constitutes an initial payment determination subject to existing administrative appeals processes.
Conclusion
WISeR represents a significant evolution in CMS’s approach to program integrity, moving beyond traditional post-payment audits to leverage technology-enabled prospective review. The model aligns with broader Department of Health and Human Services priorities to enhance transparency, expand real-time responses, and ensure that medical professionals review all clinical denials. By focusing on services already identified as vulnerable to waste and abuse while maintaining robust safeguards against inappropriate denials, WISeR seeks to demonstrate that technology can be deployed responsibly to protect both patients and taxpayers.
Stakeholders seeking additional information can subscribe to the WISeR Model listserv through the CMS Innovation Center website or contact the WISeR team directly at WISeR@cms.hhs.gov. As the model enters implementation, CMS has committed to working closely with providers, suppliers, and participants to ensure that issues are rapidly identified and resolved, with corrective actions taken as appropriate to maintain timeliness, accuracy, and transparency throughout the program.
This is an interesting program that expands the activities of the Innovation Center and is worth following despite the negative sentiment around the use of prior authorizations.
