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
Published monthly on LinkedIn.
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.
Providers are being ignored by contracted and non-contracted MA plans in their efforts to obtain a remedy for 340B drug underpayments.
A new corporate whistleblower program incentivizes reporting of healthcare fraud involving private insurance plans.
Many bills have been pending in state legislatures. Let’s take a look at what’s been recently enacted in three of those states.
State legislatures have already been busy this year. Here are some topics and bills Ensemble experts have been watching closely.
Health plans will be required to meet a prior authorization time frame as short as 72 hours, along with providing reasoning for any denials.
See how Ensemble is actually applying AI to drive value across the entire revenue cycle.
Federal agencies are scrutinizing Medicare Advantage coding with inaccurate diagnoses for enrollees with certain high-risk diagnoses.
The 2024 Medicare Advantage Final Rule clarifies that Medicare Advantage (MA) plans must follow the Two-Midnight Rule set in 2013, and more.
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.