The Centers for Medicare & Medicaid Services (CMS) recently announced the launch of the Wasteful and Inappropriate Service Reduction (WISeR) Model – a six-year pilot program designed to reduce Medicare spending on select “wasteful (low-value) services shown to have little to no clinical value.” The WISeR Model will run from January 1, 2026, through December 31, 2031, and will combine technologies, such as artificial intelligence (AI) and machine learning (ML), with clinical review to evaluate services CMS believes are vulnerable to overuse, fraud, and abuse, including skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy for knee osteoarthritis.
In general, the WISeR Model seeks to identify any fraud, waste, and abuse resulting from claims for payment for services that do not meet coverage requirements, but were paid for because such claims did not require prior authorization. To accomplish this, CMS will utilize technology companies with expertise in managing the prior authorization process for other payers (e.g., Medicare Advantage plans).
This is interesting, considering that only days before CMS unveiled the WISeR Model, the U.S. Department of Health and Human Services (HHS) Secretary Robert F. Kennedy, Jr. and CMS Administrator Dr. Mehmet Oz called for efforts to reform a “broken authorization system” and held a roundtable asking for insurers to pledge to streamline prior authorization processes in response to widespread concerns that current systems “delay or deny care to patients.” In other words, it appears that the WISeR Model will rely on the technology companies currently utilized through a system HHS believes to be “broken.”
The WISeR Model raises important questions around how it will address ongoing provider and patient concerns, presenting the potential to inadvertently replicate existing inefficiencies and frustrations under the guise of technological innovation.