On June 27, 2025, the Center for Medicare and Medicaid Innovation (CMMI) released a public notice of the Wasteful and Inappropriate Service Reduction (WISeR) Model. The six-year payment model leverages artificial intelligence (AI) and machine learning technology to support CMS’ stated aim to reduce fraud, waste, and abuse in the traditional Medicare fee-for-service (FFS) program. It will focus on prior authorization and/or prepayment review processes for select services from providers and suppliers.
Under the WISeR Model, CMS will contract with third-party technology vendors (participants) to review provider and supplier claims for a predefined list of services that CMS believes are prone to overuse and improper billing. This list of services is provided in the Provider and Supplier Operational Guide.
When Does the WISeR Model Start, & Who Will Be Affected?
The WISeR Model will begin on January 1, 2026, and will be piloted in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington. All FFS providers and suppliers in the pilot states will be subject to the model requirements for traditional Medicare patients and the list of predefined services. While WISeR is technically a voluntary model, it will be functionally mandatory, as claims that are not submitted for prior authorization will be automatically subject to the prepayment review process.
How Does the CMS WISeR Model Work?
Providers and suppliers of the services on the predefined list will be required to participate in a medical necessity review through one of three paths:
- A direct prior authorization request to the WISeR technology vendor for review and determination.
- A prior authorization request to the Medicare Administrative Contractor (MAC), who will route it to the WISeR technology vendor for review and determination.
- An automatic prepayment medical review process initiated by the WISeR technology vendor for services furnished without requesting prior authorization. This will include a request for clinical documentation related to the claim.
Providers and suppliers can send prior authorization requests through standard methods (mail, fax, and electronic portal). Technology vendor participants will be expected to process requests within three days for standard requests and two days for urgent requests. Providers and suppliers that do not submit a prior authorization request will have 45 days from the date of the documentation request to provide the requested information for prepayment review.
In the event of a non-affirmation decision, providers and suppliers are permitted an unlimited number of resubmissions and may request a peer-to-peer review to discuss the denied decision and other clinical options. In addition, certain providers and suppliers that achieve a provisional affirmation rate of 90% or higher during a designated performance review period may be granted an exemption from the prior authorization process.
Who Are the Technology Vendors Participating in the WISeR Model?
The participants are companies CMMI has deemed to have the experience and capabilities to perform medical necessity review assisted by technology, including AI and machine learning. The list of participants assigned to each state and MAC jurisdiction is provided in the “Participant Information” section on CMS' WISeR Model webpage.
How Can Healthcare Provider Organizations Prepare for the CMS WISeR Model?
WISeR may require a significant administrative lift for providers and suppliers subject to the model. Organizations should consider the following items as they prepare:
- Stay Up to Date: WISeR is a demonstration/pilot program and therefore may undergo changes in approach and design. Providers should keep up with the latest CMS announcements to track potential expansions or revisions to the scope of the program. The WISeR Model has also faced recent challenges in the U.S. House of Representatives, so providers should keep an eye out for potential legislation that could impact the program.
- Workflows & Staffing: Providers should consider implementing revised workflows to support adherence to the new WISeR requirements, including:
- Standard procedures to identify, submit, and perform follow-up on cases subject to the prior authorization or prepayment review process
- Staffing needs to perform the administrative submission and follow-up
- Technology that can help automate and support tracking and completion of prior authorization or preservice payment requirements
- Monitor & Measure Performance: Providers should consider developing tools and analytics to monitor and measure completion of authorization and/or prepayment review requirements, appeal success, and revenue impact.
How Forvis Mazars Can Help
Our healthcare and revenue cycle professionals are committed to helping organizations prepare and adapt to the WISeR Model and other evolving regulatory requirements. If you have questions about how the WISeR Model may affect your organization or how you can prepare, please reach out to our team today.