Some Medicare-covered services will be subject to prior authorization in some parts of the country under a new model to be launched by the Centers for Medicare & Medicaid Services next year.

To run from 2026 through 2031, the “Wasteful and Inappropriate Service Reduction Model,” or WISeR, will test a new process for determining whether enhanced technologies, including artificial intelligence, can expedite prior authorization for selected items and services that have been identified by CMS as particularly vulnerable to fraud, waste, abuse, or inappropriate use.  The model will not include inpatient-only services, emergency services, and “…services that would pose a substantial risk to patients if significantly delayed.”  The companies to be chosen to administer the prior authorization will have “…expertise with managing the prior authorization process for other payers using enhanced technology like AI.”

The model will not operate nationwide.  WISeR will be implemented in selected MAC jurisdictions and only some states within those jurisdictions:  MAC areas JH, JL, JF, and J15 and the states of New Jersey (JL/Novitas), Ohio (J15/CGS), Oklahoma and Texas (JH/Novitas), and Arizona and Washington (JF/Noridian).

The companies selected to participate in the model will operate in assigned geographic regions and must have clinicians with appropriate expertise to conduct medical reviews and validate coverage determinations.  While technology will support the review process, final decisions that a request does not meet Medicare coverage requirements will be made by licensed clinicians.

The prior authorization companies will be paid based on their ability to reduce unnecessary or non-covered services and reduce spending in traditional Medicare.  CMS payments to these companies will be adjusted based on their performance against established quality and process standards that measure their ability to support faster decision-making for providers and suppliers and improve provider, supplier, and beneficiary experience with the prior authorization process.

The WISeR Model, to be administered by CMS’s Center for Medicare and Medicaid Innovation, will not change Medicare coverage or payment criteria or the ability of beneficiaries to seek care from their providers or suppliers of choice.  Medicare Advantage plans will not be participating in this program.

CMS plans to launch WISeR on January 1, 2026.

Learn more about the WISeR model from the following resources: