CMS has announced a regional, pilot program to test Prior Authorization of targeted services in Fee for Service Medicare.
While none of these are genomic tests or PET imaging, diagnostic providers should still track this initiative for future implications.
- ...Third party entities [will be] leveraging enhanced technologies, that would be paid under a novel payment approach where the model participants are compensated based on a share of averted expenditures. Further, the WISeR model would test: the speed and accuracy of new technology-assisted decision-making. 90FR28751.
Wow. "Compensated based on a share of averted expenditures" or in plain English, "paid for claims denied."
- See press release here - June 27, 2025.
- See two-page fact sheet here.
- See home page for the project, WISeR, at Center for Innovation, here.
- See 35-page project description and Request for Applications here.
- See FAQ here.
- See one-pager here.
- See Fed Reg here - 90 FR 28749, 5pp, July 1, 2025.
- See article at "Kiplinger," here.
- See a Medicare Advantage portal for genomics pre-authorization here.
WISeR Model: A Health Policy Overview of Third-Party “Model Participants” Coordinating with MACs
[AI generated article]
The Wasteful and Inappropriate Service Reduction (WISeR) model, launched by the CMS Innovation Center, represents a bold new approach to prior authorization in Medicare Fee-for-Service (FFS). Running from 2026 to 2031, the WISeR model is structured as a 6-year, two-phase demonstration project designed to test the use of enhanced technologies such as artificial intelligence (AI) and machine learning (ML) to improve oversight and reduce unnecessary or inappropriate services in Original Medicare.
❖ Purpose and Scope of WISeR
CMS estimates that up to 25% of U.S. health care spending is wasteful, including billions in Medicare expenditures. Services targeted in WISeR include those with little or no clinical benefit, as well as services vulnerable to fraud, waste, and abuse (FWA). Examples include:
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Skin and tissue substitutes
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Electrical nerve stimulators
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Knee arthroscopy for osteoarthritis
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Spinal injections, vertebroplasty, and hypoglossal nerve stimulation
Crucially, Medicare Advantage (MA) plans have demonstrated success using enhanced prior authorization tools; WISeR now tests the transferability of such strategies into the Original Medicare space.
❖ Who Are the “Model Participants”?
In contrast to many CMMI models that engage providers or health systems, WISeR’s only participants are third-party technology companies—not health care providers or insurers.
These model participants are:
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Private-sector companies with prior experience in streamlining prior authorization for Medicare Advantage or commercial payers;
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Firms that use enhanced technologies, including AI/ML algorithms, predictive analytics, and electronic portals;
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Required to include appropriately licensed human clinicians to make final non-affirmation decisions, consistent with Medicare's requirement that adverse decisions are clinically reviewed.
These entities coordinate directly with Medicare Administrative Contractors (MACs) to process prior authorization requests and associated claims reviews.
CMS refers to these participants as technology innovators—companies that will serve as delegated prior authorization reviewers in designated states.
Participants are compensated not via fee-for-service, but through a shared savings model based on averted Medicare expenditures attributed to their interventions.
❖ Coordination with MACs
WISeR introduces a triangular workflow:
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Providers and suppliers submit prior authorization (PA) requests:
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Either to the MAC, which forwards it to the model participant,
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Or directly to the model participant, who conducts the review.
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Model participants use their AI-powered platforms to evaluate documentation, determine coverage, and issue provisional affirmations (or not).
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The MACs then:
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Receive a unique tracking number (UTN) from the model participant to process claims accordingly,
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Conduct post-payment actions for any claims not submitted through prior authorization.
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Claims without a prior authorization will be subject to pre-payment medical review by the model participant, again coordinated via the MAC.
This system is designed to reduce administrative burden, especially for compliant providers who may qualify for "gold card" exemptions, and to standardize the interface between CMS systems and the private sector.
❖ Oversight and Quality Metrics
Model participants will be evaluated on:
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Volume of requests processed
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Timeliness of decisions
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Appeal overturn rates
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Beneficiary experience
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Clarity of documentation and communication
Final authority over non-affirmations lies with licensed clinicians, not machines—ensuring ethical oversight.
❖ Geographic Coverage and Implementation
WISeR will be piloted in six states across four MAC jurisdictions:
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JL: New Jersey
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J15: Ohio
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JH: Oklahoma, Texas
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JF: Arizona, Washington
These jurisdictions were selected for their claim volume, LCD infrastructure, and evaluability across control and test states.
❖ Conclusion
WISeR represents a major structural innovation in Medicare policy: contracting directly with private technology firms to manage utilization review, guided by AI but grounded in traditional clinical standards. This shift challenges CMS’s historic reliance on MACs and provider-led models by introducing a novel, delegated review system focused on efficiency, accuracy, and savings.
As the first model where CMS pays third-party vendors a cut of averted expenses, WISeR’s outcome will likely influence future efforts to modernize Medicare FFS oversight and incorporate private-sector technology innovations into federal healthcare administration.
