Industry Watch Alert
Operational Structure
- The WISeR Model will run for two three-year agreement periods, monitored for accuracy, timeliness, and reduction of unnecessary care.
- Initial performance year will focus on the select set of services. The list may expand in later years based on policy criteria and CMS evaluation.
- Model participants (vendors) must comply with strict security, performance, and reporting standards.
During the American Medical Association’s October 22, 2025 webinar focused on the WISeR model, Director of the Center for Medicare & Medicaid Innovation and CMS Deputy Administrator Abe Sutton confirmed that a government shutdown will not impact the project’s scheduled launch.
He explained that payment model demonstrations at CMS proceed under separate Innovation Center funding authorized by Congress, and that ongoing statutory requirements obligate the center to continue its testing activities regardless of federal budget circumstances.
key takeaways
- The WISeR Model launch remains scheduled for January 1, 2026, in the six pilot states, even in the event of a government shutdown.
- WISeR will initially apply prior authorization or pre-payment review to a designated list of outpatient and device-related services; examples confirmed include electrical nerve stimulator implants, skin and tissue substitutes, lumbar decompression, vertebral augmentation, and certain injections for pain management (e.g., epidural steroid injections).
- CMS will contract with third-party technology vendors (“model participants”) to manage prior authorization and reviews; as of October 2025, these contractor assignments are not finalized or publicly announced.
- Providers and suppliers in pilot states must follow the WISeR workflow for select services –submitting prior authorization requests or subjecting claims to pre-payment review. Participation is technically voluntary, but claims submitted outside WISeR pathways risk delay or denial.
- Professional groups and policymakers have publicly raised concerns about administrative burden and implementation, but the agency maintains its timeline for launch.
- The pilot is intended by CMS to evaluate scalable prior authorization methods for Original Medicare, including use of AI and machine learning in processing, and may influence future federal policy or expansion into commercial markets.
Wiser Model Purpose & Process
- The WISeR Model was created by the Center for Medicare & Medicaid Innovation to test new technology-enhanced payment and service delivery approaches in Original Medicare that reduce unnecessary treatments and prevent fraud, waste, and abuse, while maintaining or improving quality of care. Its primary aim is to ensure select items and services for Medicare beneficiaries meet established coverage criteria by leveraging advanced technologies and dedicated review organizations, thereby promoting safe, effective, and clinically necessary care without changing existing Medicare coverage or payment policies. [provider & supplier operational guide]
- Providers may submit prior authorization requests before servicing; non-submission triggers pre-payment review—a process requiring medical necessity documentation, NCD/LCD compliance, and clinical validation by WISeR participants.
- All determinations and reviews will be supervised by licensed clinicians with subject-matter expertise.
- Gold Card exemption is planned for select providers meeting documentation and compliance criteria, with further implementation details to be released by CMS.
Summary
WISeR’s launch remains on track for January 2026 in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. The prior authorization/pre-payment review pilot applies to specified outpatient and device procedures, managed by third-party vendors pending final assignment. Provider adherence to WISeR workflows is required for affected services. The operational scope, monitored metrics, and future policy implications are outlined by CMS, with further service list details and contractor guidance expected before full launch. As of 10/30/25, approved vendors have not yet been announced.
Sources
- Centers for Medicare & Medicaid Services. Wasteful and Inappropriate Service Reduction (WISeR) Model – Frequently Asked Questions. Retrieved September 2025, from https://www.cms.gov/priorities/innovation/files/document/wiser-model-frequently-asked-questions CMS
- Centers for Medicare & Medicaid Services. Wasteful and Inappropriate Service Reduction (WISeR) Model – Fact Sheet. April 2025. Retrieved from https://www.cms.gov/files/document/wiser-fact-sheet.pdf CMS
- Centers for Medicare & Medicaid Services. *WISeR Model Webpage: Innovation Models». Retrieved September 2025, from https://www.cms.gov/priorities/innovation/innovation-models/wiser CMS
- Centers for Medicare & Medicaid Services. CMS Launches New Model to Target Wasteful, Inappropriate Services in Original Medicare. Press Release, June 27 2025. Retrieved from https://www.cms.gov/newsroom/press-releases/cms-launches-new-model-target-wasteful-inappropriate-services-original-medicare CMS
- Centers for Medicare & Medicaid Services / Federal Register. Medicare Program; Implementation of Prior Authorization for Select Services for the Wasteful and Inappropriate Services Reduction (WISeR) Model. Federal Register notice, July 1 2025 (Document 2025-12195). Retrieved from https://public-inspection.federalregister.gov/2025-12195.pdf public-inspection.federalregister.gov
FAQ
- Will WISeR apply only in a few states or nationwide?
a. The pilot model applies initially in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington.
b. If you are a provider or supplier operating in one of these states and you furnish a service included in Year 1, you are subject to the model’s workflow (either prior authorization or pre-payment review). If you are outside those states, this pilot does not apply for now but it may indicate what is coming.
c. Assess your network exposure now: map which of your providers/suppliers are in these states, delivering any of the listed service categories. - Does participating in WISeR change Medicare coverage or payment rates?
a. No, the model does not alter coverage or payment amounts under Original Medicare.
b. What changes is the process of how certain services are reviewed: you either submit a prior authorization request in advance, or you proceed and then face pre-payment medical review. If your documentation is insufficient or a determination is “non-affirmed,” payment delay or denial risk increases.
c. For payers and providers, the takeaway is process readiness not benefit-policy change. Build your workflow accordingly. - If a provider does not submit a prior authorization request, what happens?
a. They may still furnish the service but the claim will be subject to pre-payment medical review by the WISeR model participant.
b. That means documentation must be able to demonstrate clinical necessity, meet NCD/LCD criteria, include all required data elements, and still pass the medical review. If it fails, the associated items and services may also be denied (devices, ancillary services) because they hinge on the primary service being affirmed.
c. Verify that your provider networks understand the trade-off: either participate in the prior authorization path (with its own lead time and workflow) or assume the risk of claim suspension/delay via pre-payment review. - What is the “Gold-Card” (exemption) path and how should providers think about it?
a. The model includes a concept of exemption (“gold-carding”) for providers/suppliers with a strong compliance record; those may eventually bypass full prior authorization or review.
b. While the details are not yet fully finalized, the idea is that providers with demonstrated documentation accuracy, low denial rates and timely turnaround may qualify. That creates a competitive advantage; less administrative burden, faster throughput. However, the process to qualify remains opaque for now.
c. Providers and payers should strategize now for “gold-card eligibility” by tracking internal prior-authorization metrics (approval rates, turnaround times, documentation completeness) and building workflows that aim for excellence. Positioning earlier may yield advantage when CMS publishes criteria.
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