Understanding CMS’ New WISeR Program

In a move aimed at addressing the persistent challenge of high healthcare spending, the Centers for Medicare & Medicaid Services (CMS) recently launched a new payment and oversight model called WISeR, short for “Wasteful and Inappropriate Service Reduction.” Set to begin in January 2026 and run through 2031, WISeR is designed to use artificial intelligence (AI) to identify and reduce the provision of services that Medicare deems unnecessary, duplicative, or low value. While its goals are familiar, the model marks a shift in how CMS is approaching prior authorization, technology use, and provider oversight.

For healthcare providers, WISeR represents both a policy change and a shift in operational workflow, especially for those practicing in the six participating states: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. Although the model is technically focused on a limited number of outpatient services, including certain spinal procedures, wound care treatments, and pain management interventions, its implications could be far-reaching.

WISeR does not alter Medicare’s coverage or payment rules. Instead, it changes the process through which specific services are reviewed before payment is made. Providers in participating states will face two main options: they can submit prior authorization requests through CMS-approved technology vendors or have claims for selected services reviewed through a more rigorous prepayment review process.

The WISeR model involves AI-driven tools to support the review of claims and prior authorization requests. These tools are intended to streamline reviews and reduce unnecessary back-and-forth between providers and Medicare. However, CMS has emphasized that no claim or request will be denied based solely on an automated decision. All denials must be reviewed and confirmed by a licensed clinician. For Medicare enrolled providers familiar with the often uninformed and arbitrary decisions of CMS contractors, the injection of an AI tool may come as a welcome change.

One of the most important questions for providers is how WISeR will impact workflow. Many clinicians already express frustration with the administrative burden of prior authorization. CMS claims that WISeR will simplify the process over time by using more consistent, data-driven criteria and by giving high-performing providers more flexibility. Providers who demonstrate high compliance with clinical guidelines could eventually be exempted from certain review processes, an approach sometimes referred to as “gold carding.”

Several provider groups and members of Congress have raised flags about the model’s potential to delay care, increase documentation burdens, and create perverse incentives for vendors who are financially rewarded based on the volume of services they help deny. Significant questions remain regarding the implementation of the program. Providers in states subject to the pilot program should educate themselves about the program and prepare for challenges that may arise under it.

For over 40 years, Wachler & Associates has represented healthcare providers and suppliers nationwide in a variety of health law matters, and our attorneys can assist providers and suppliers in understanding new developments in healthcare law and regulation. If you or your healthcare entity has any questions pertaining to WISeR or healthcare compliance, please contact an experienced healthcare attorney at 248-544-0888 or wapc@wachler.com.