Posted on Thursday, September 18, 2025
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by Sabrinah Cave
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1 Comments
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Beginning January 1, 2026, for the first time, Original Medicare will test prior authorization requirements for specific services through the new WISeR Model.
What Is the WISeR Model?
WISeR stands for Wasteful and Inappropriate Service Reduction. Waste accounts for 25% of spending in the United States healthcare system. The WISeR Model is a six-year pilot program designed to curb fraud, waste, and abuse in Original Medicare. Starting January 1, 2026, this program will be deployed in 6 states: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington.
The WISeR Model applies prior authorization and pre-payment medical review to 17 services deemed vulnerable due to low clinical value or high risk of misuse. CMS partnered with technology companies who will use enhanced tools like artificial intelligence and machine learning to conduct these reviews.
CMS required the partnering tech companies to employ “clinicians with the expertise to conduct medical reviews to validate determinations” for additional oversight. Additionally, all final determinations to deny a claim will be made by licensed human clinicians, not automated systems.
Services Subject to Prior Authorization
The WISeR Model targets services known for overuse or limited clinical benefit, including but not limited to:
- Skin and tissue substitutes
- Electrical nerve stimulator implants
- Knee arthroscopy for osteoarthritis
- Cervical fusion and epidural steroid injections
- Deep brain stimulation for Parkinson’s disease
Providers may submit a either prior authorization request before performing the service to ensure coverage or face a post-service medical review. The latter choice runs the risk of potential denials or non-payment for claims that don’t meet criteria.
Goals and Oversight
By implementing the WISeR Model, CMS aims to:
- Reduce unnecessary or low-value care
- Protect federal taxpayer dollars
- Ensure Medicare beneficiaries receive medically appropriate and safe services
- Encourage transparent medical necessity reviews using AI integrated processes
Partnered tech companies will be compensated based on their ability to help lower spending and avoid inappropriate utilization. Review volume, processing timeliness, and determination clarity also factor into payment calculations.
If successful, the WISeR Model may be extended to new states or additional services. CMS may also introduce a “gold carding” process to exempt providers with high prior authorization approval rates from future reviews, reducing administrative burdens.
Concerns from Medicare Providers
Medical groups and physician advocates warn the new prior authorization pilot program may increase administrative burdens, delay care, and challenge provider autonomy.
As Anders Gilberg from the Medical Group Management Association stated:
“One of the hallmarks of Original Medicare has been the ability for physicians, not government, to determine what’s clinically appropriate for their patient.”
Critics also question whether AI-driven prior authorization structures may incentivize denials, pointing to Medicare Advantage’s long-standing track record of denials tied to cost savings.
What Medciare Beneficiaries in The Six Selected States Can Expect
If you have Original Medicare plus a Medicare Supplement plan (Medigap), you may encounter prior authorization reviews. This is because Original Medicare is your primary coverage. Your provider can choose to either submit the prior authorization review before services are rendered, or complete a post-service medical review afterwards.
On the other hand, since Medicare Advantage plans replace Original Medicare, coverage decisions for enrollees will still be made by insurers. However, your plan carrier may have new or updated prior authorization requirements in 2026.
Ultimately, decisions on denial or approval will remain clinical, but providers may face new paperwork and delays in administering care. Coverage criteria, medical necessity standards, and Medicare beneficiaries’ rights remain unaltered, but the WISeR Model adds additional review steps for select services.
Key Takeaways
- CMS will introduce prior authorization to Original Medicare for the first time via a six-state pilot called the WISeR Model.
- Running from 2026 through 2031, the pilot targets 17 services prone to overuse and waste.
- CMS partners with tech-based review firms while human clinicians make final coverage decisions.
- Providers can opt in with PA requests or face pre-payment medical review.
- While intended to improve program integrity and reduce waste, the WISeR Model has sparked concerns around administrative burden and patient access delays.
Providers in the six participating states should prepare for upcoming changes by reviewing WISeR guidance from CMS and updating billing practices. Patients should consult their providers about whether services they expect to receive are on the WISeR list and clarify the prior authoriztion process.
For help with Medicare plans – or any questions you may have about Medicare – contact AMAC’s Medicare Advisory Service at 1-855-611-4856 or request a quote below.
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