The WISeR Model: Using AI in a New Era of Prior Authorizations for Medicare
The Wasteful and Inappropriate Service Reduction (WISeR) Model introduces prior auths for select services at risk of fraud, waste and abuse.
November 5, 2025
The Wasteful and Inappropriate Service Reduction (WISeR) Model introduces prior auths for select services at risk of fraud, waste and abuse.
Shifts in federal policy may lead to more activity at the state level. Here some state bills seeking to regulate the use of AI in healthcare.
A new corporate whistleblower program incentivizes reporting of healthcare fraud involving private insurance plans.
Health plans will be required to meet a prior authorization time frame as short as 72 hours, along with providing reasoning for any denials.
A report from the OIG found some MCOs have unusually high rates of prior authorization denials, with limited or no state oversight.
This new rule introduces several key changes that will promote transparency and consistency in healthcare coverage decisions.
Cigna added to the list of codes to be denied if billed without a corresponding CPT or HCPCS code starting May 1, 2023.
Key changes promote transparency in coverage decisions for MA beneficiaries, while ensuring providers can offer the best care for patients.
CMS issued a proposed rule that could change utilization management and prior authorization criteria for Medicare Advantage plans.
OIG and CMS agree more scrutiny is needed for Medicare bad debt reimbursement and encourage more regular review of bad debts claimed.
The OIG issued an Advisory Opinion on nurse practitioners providing services that are traditionally performed by primary care physicians.
A federal court decision highlights the risk providers may face if they do not comply with Medicare Bad Debt regulations.