WASHINGTON, D.C. — The Centers for Medicare & Medicaid Services (CMS) has unveiled a new initiative aimed at improving prior authorization processes for Original Medicare beneficiaries. Announced last week, the Wasteful and Inappropriate Service Reduction (WISeR) Model seeks to expedite care authorization, reduce unnecessary and inappropriate services, and protect federal taxpayer dollars by leveraging advanced technologies and clinician expertise.
The WISeR Model will test innovative tools, including artificial intelligence, to streamline prior authorization for certain items and services identified as prone to fraud, waste, abuse, and misuse. These include skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy procedures for osteoarthritis. While technology will enhance efficiency, all coverage denial decisions will be made solely by licensed clinicians.
“CMS is committed to crushing fraud, waste, and abuse, and the WISeR Model will help root out waste in Original Medicare,” said CMS Administrator Dr. Mehmet Oz. “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.”
Low-value care—which provides little to no clinical benefit and sometimes risks physical or psychological harm to patients—is estimated to account for up to 25% of U.S. healthcare spending. CMS noted that in 2022, Medicare spent $5.8 billion on services with minimal value. Abe Sutton, Director of the CMS Innovation Center, emphasized the importance of the WISeR Model’s goals, stating, “Low-value services, such as those of focus in WISeR, offer patients minimal benefit and, in some cases, can result in physical harm and psychological stress. They also increase patient costs, while inflating healthcare spending.”
Under the initiative, participating companies will work within designated regions to oversee prior authorization requests and pre-payment medical reviews. Payments to participants will be contingent on their ability to reduce unnecessary services and lower Medicare spending while meeting measures for quality, efficiency, and provider satisfaction.
The WISeR Model does not change coverage criteria for Medicare beneficiaries and allows them to maintain full freedom in selecting providers. Furthermore, CMS is considering future pathways to exempt providers with strong compliance records from WISeR reviews, which could reduce administrative burdens for trusted entities. The program’s preauthorization processes will not affect inpatient-only, emergency, or high-risk services. Importantly, WISeR applies exclusively to Original Medicare beneficiaries and does not impact Medicare Advantage plans.
CMS has issued a Request for Applications inviting technology companies and healthcare enterprises to participate in this pilot model. The initiative represents a proactive effort to modernize Medicare operations while safeguarding healthcare resources and improving the experience for patients and providers alike.
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