The Centers for Medicare & Medicaid Services (CMS) is launching the Wasteful and Inappropriate Service Reduction (WISeR) Model on January 1, 2026 — a bold, six-year initiative designed to tackle fraud, waste and abuse (FWA) in Medicare Fee-for-Service (FFS) by using advanced technologies — artificial intelligence (AI) and machine learning (ML) — to introduce prior authorization for select services at higher risk of FWA in certain selected states.
This model arrives at a critical moment where there’s heightened industry interest in incorporating AI into workflows along with heighted Federal interest in reducing FWA spending generally across the government. Its importance to FWA is further highlighted by a September 2025 Health and Human Services (HHS) Office of Inspector General (OIG) report, which found that Medicare Part B spending on one of the targeted services, skin substitutes, exceeded $10 billion in 2024, with alarming trends in utilization, pricing and fraud schemes.
The model, however, faces practical and political obstacles to its January 1 launch date. Practically, key details about the program remain unknown, and the ongoing government shutdown likely delays final decisions and communications about it from CMS.
Politically, several members of Congress have criticized WISeR, warning that its AI-driven prior authorization process could delay or deny necessary care for Medicare beneficiaries. Lawmakers argue the model threatens patient access and mirrors problematic practices in Medicare Advantage. A House resolution was introduced in September to halt the model, followed by a proposed amendment to the HHS funding bill to block funding of the model. The status of this opposition remains unresolved during the ongoing government shutdown. The American Hospital Association also recently voiced its concerns with the model and urged CMS to delay its launch by six months.
What is the WISeR Model?
WISeR is a CMS Innovation Center initiative focused on reducing unnecessary and inappropriate services in Medicare FFS by using AI and ML to streamline prior authorization (PA) and medical review processes for items and services vulnerable to FWA, such as skin substitutes, electrical nerve stimulators and knee arthroscopy for osteoarthritis.
WISeR’s implementation is driven by the vulnerability of certain Medicare services to FWA, rising concerns of overuse and patient safety. With significant wasteful spending — up to 25% of U.S. healthcare costs per CMS — and documented fraud in areas like skin substitutes, CMS seeks to leverage AI and ML to modernize oversight and ensure care is both clinically beneficial and safe for patients while also ensuring payment complies with Medicare rules.
WISeR is not a mandatory model for Medicare providers in the selected states of Arizona, New Jersey, Ohio, Oklahoma, Texas, Washington. Providers in these states will have the option to submit a prior authorization request or go through a post-service/pre-payment review. WISeR does not change Medicare coverage or payment policy.
How does WISeR work?
- Model Participants: Companies selected by CMS with expertise in AI and ML tech-enabled PA will perform reviews and issue a prior authorization decision (affirmation or non-affirmation) of the requested procedure. Non-affirmation decisions require the review of a licensed clinician prior to issuance. The Model Participants’ compensation is controversially tied to the amount of savings associated with their denials. These AI vendors have not yet been announced by CMS.
- Targeted services: WISeR identifies high-cost, high-risk Medicare Part B services for review, including skin and tissue substitutes, electrical nerve stimulators, knee arthroscopy and more. Excludes inpatient, emergency and risky delayed services.
- Provider participation: As previously stated, the model is optional, so providers in selected states (Arizona, New Jersey, Ohio, Oklahoma, Texas, Washington) can choose to submit PA requests for targeted services or proceed with rendering the services understanding the claim will undergo pre-payment review.
- Submitting a prior authorization request: Providers in designated regions who choose to submit a PA request will submit supporting documentation for the targeted service to either their regional MAC with the MAC routing to the Model Participant or directly to the Model Participant who will then use AI and ML tools to perform its review to make a coverage decision.
- Decision issued: The Model Participant notifies the provider of its decision to affirm or not affirm the service. If affirmed, the Model Participant will provide a unique tracking number to inform a payment determination when the claim is submitted. If not affirmed, the provider may either resubmit its request (unlimited opportunities to do this) or request a peer-to-peer review.
- Gold Carding: Providers with demonstrated records of compliance may receive exemption from PA requirements, subject to compliance monitoring.
- Safeguards: All data sharing is HIPAA-compliant, and the appeals process remains unchanged for denied claims.
- Medicare coverage and payment policies remain the same. WISeR does not change Medicare coverage or payment policy.
How is Ensemble addressing WISeR's implications for providers?
The WISeR Model has key implications for providers:
- Providers in the selected states must choose whether to adopt these new PA processes or risk claims for targeted services being pended for pre-payment review or potentially denied.
- High performers may benefit from reduced administrative burden through gold-carding.
WISeR represents a pivotal shift in CMS oversight by introducing prior authorization requirements to Medicare FFS services. For CFOs and financial leaders of healthcare providers, proactive engagement with WISeR’s design and opportunities will be key to driving success with the model’s requirements.
At Ensemble, we are actively working to position our clients for success under WISeR. For states impacted by WISeR where we have a client footprint, we are focusing on identifying impacted procedures, engaging vendor partners and building automation into prior authorization workflows. Our teams are currently mapping these areas and initiating discussions with vendors to align planning and next steps.
This approach ensures that when CMS announces approved AI vendors (i.e., Model Participants), we will be ready to integrate prior authorization processes quickly and effectively, so as to avoid pre-payment medical reviews and potential denials. This approach also positions our clients for success in qualifying for gold-carding.
Our goal is to automate as much as possible across all client platforms. In this way, we can reduce administrative burden and accelerate approvals through configuration of existing systems, streamlined routing logic for documentation and integration with external authorization solutions and approved CMS vendor solution partners.
By acting now, we aim to ensure our clients are prepared, compliant and positioned to leverage automation for efficiency and cost savings under the WISeR Model.
