New CMS Program Targets Unnecessary Services in Original Medicare

The Centers for Medicare & Medicaid Services (CMS) has announced a new pilot model called WISeR, short for Wasteful and Inappropriate Service Reduction. This six-year program is designed to reduce unnecessary services in Original Medicare and modernize the prior authorization process using data-driven tools.

‍

The WISeR model launches on January 1, 2026, and will run through December 31, 2031.

‍

CMS Aims to Reduce Unnecessary Spending

CMS estimates that Medicare paid more than $5.8 billion in 2022 for services that may not have provided meaningful benefit to patients. The WISeR model is intended to address these concerns by testing new ways to identify, reduce, and prevent low-value care.

Instead of relying solely on traditional post-payment reviews, WISeR will use real-time data to identify services that are frequently overused, misused, or vulnerable to fraud. The program is expected to reduce administrative burden for providers while improving efficiency and accuracy.

‍

How the WISeR Model Will Work

Under WISeR, CMS will partner with technology vendors that use advanced analytics, including machine learning, to support the prior authorization process. These vendors will assist in reviewing select outpatient services before they are provided. A licensed physician or other qualified healthcare professional will make the final coverage determination, ensuring medical appropriateness remains central to decision-making.

Participation is voluntary. Providers can choose to submit prior authorizations through WISeR or continue using the standard process.

The model will initially apply to certain services known for overuse, such as:

• Skin substitutes
• Electrical nerve stimulator implants
• Spinal and knee procedures
• Selected durable medical equipment

Emergency and inpatient-only services will not be included.

‍

Pilot Will Roll Out In Select States

The WISeR model will begin in six states:

• Arizona
• Florida
• Georgia
• New Jersey
• New York
• Ohio

CMS selected these states to provide a mix of provider types and geographic variation. Only a limited number of services will be subject to review during the pilot phase. CMS will use the results to evaluate whether the approach could be expanded nationally.

‍

Incentives for Technology Vendors

Approved technology vendors will be eligible to receive a portion of the savings generated through the program. Compensation will be tied to performance on several metrics, including accuracy, timeliness, quality, and provider satisfaction.

These vendors must demonstrate that their systems can support fast and reliable prior authorization decisions without delaying patient care.

‍

What Providers Should Know

CMS is accepting applications from technology vendors through July 25, 2025. More information about eligibility, model design, and provider participation will be released over the coming months.

Although WISeR does not change existing Medicare coverage rules, it could lay the groundwork for broader use of prospective utilization review in the future.

‍

More on WISer can be found in the CMS Press Release.