CMS launches new model to test prior authorization improvements

CMS recently announced it will partner with companies specializing in enhanced technologies to test improvements to prior authorization processes via a new Innovation Center model. The Wasteful and Inappropriate Service Reduction (WISeR) model is voluntary and will run for six performance years from January 1, 2026, to December 31, 2031.

WISeR model participants will be certain companies with expertise in managing prior authorization requests for payers using artificial intelligence, machine learning, and other technologies. These companies will be required to use clinician reviews to validate their determinations. However, providers and suppliers are not required to submit a prior authorization request for a selected item or service.

WISeR model participants will receive payments based on their ability to reduce inappropriate utilization and lower spending in traditional Medicare. Payment adjustments will be based on process quality, provider/supplier and beneficiary experience, and clinical quality outcome performance measures.

The selected geographic areas for the WISeR model include Arizona, Ohio, Oklahoma, Texas, Washington, and New Jersey. All Medicare providers and suppliers in these regions will have the option to submit a prior authorization request for items and services included in the model or go through a post-service/pre-payment review, according to CMS. The prior authorization request may either be submitted directly to the model participant or their Medicare Administrative Contractor, who would then forward the request to the participant.

Examples of items and services included in the WISeR model include skin substitutes, implantation of electrical nerve stimulators, and knee arthroscopy for knee osteoarthritis. CMS noted that the model does not include inpatient-only services, emergency services, and services that would pose a substantial risk to patients if delayed.

The WISeR model does not change Medicare coverage or payment policy for the selected items or services, and it will not impact patients with Medicare Advantage, according to CMS.

The WISeR model request for applications is open through July 25. Revenue integrity professionals can view CMS’ fact sheet and FAQ for more information.