The Centers for Medicare & Medicaid Services Center for Medicare and Medicaid Innovation (CMMI) on June 27 announced details for the new Wasteful and Inappropriate Service Reduction (WISeR) Model. The WISeR Model will run for six years, beginning in 2026, and will test prior authorization for additional Part B services in traditional Medicare for providers in the following states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington.
Under the model, providers in those states will have a choice of whether to submit a prior authorization request or undergo a post-service prepayment medical review for specific items and services. Providers who choose the prior authorization option may either submit the request directly to a model participant or submit the request to their Medicare Administrative Contractor that will forward the request to the model participant. Model participants are companies “with expertise managing the prior authorization process for other payers using enhanced technology like AI” and are required to have clinicians with expertise to conduct medical reviews to validate determinations. Companies hired to manage the initiative will be paid based on how much money they save the federal government by stopping payment for unnecessary or noncovered items and services.
The initial list of planned items and services for the first performance year of the model includes deep brain stimulation for Parkinson’s disease, epidural steroid injection for pain management, cervical fusion, skin and tissue substitutes, and knee arthroscopy for osteoarthritis. The model excludes inpatient-only services, emergency services, and services that, if substantially delayed by a prior authorization, would pose a risk to patients.
- Washington Highlights