CMS’s Wasteful and Inappropriate Service Reduction (WISeR) Model brings AI-augmented prior authorization into Traditional Medicare across six states (AZ, NJ, OH, OK, TX, WA) starting Jan 1, 2026. It targets a defined list of procedures deemed vulnerable to low-value use or fraud, does not change Medicare coverage rules, and currently excludes inpatient, emergency services, and services that would pose substantial risk if delayed. CMS will contract with third party companies to test utilizing AI to process prior authorizations for select procedures. Contracted companies will be paid a share of “savings” tied to reduced spending—creating real concerns about delays/denials and added provider burden. While buy-and-bill drugs are not included at launch, if WISeR is adopted, the logic that drives utilization controls will almost certainly extend to specialty medications, where patient access barriers already harm outcomes.
WISeR is a six-year CMS Innovation Center test that uses enhanced technologies (including AI/ML) to process prior authorizations for a subset of outpatient services in Traditional Medicare. CMS will contract with organizations that already manage prior authorizations for other payers and those companies will apply their technology to assess requests against existing Medicare coverage rules. Coverage policies themselves do not change under WISeR.
Where/when: WISeR runs Jan 1, 2026 – Dec 31, 2031 in AZ, NJ, OH, OK, TX, WA (one participant per MAC jurisdiction).
What’s included at launch: An initial list of procedures (ex. electrical nerve stimulators; knee arthroscopy for OA; skin/tissue substitutes), chosen for patient-safety and low-value-care concerns. Inpatient-only and emergency services are excluded, and CMS emphasizes licensed clinicians must determine non-payment decisions. Buy-and-bill drugs are not listed in the initial set.
Provider options: Providers can submit prior auth to the participant (or via the MAC), or skip PA and face pre-payment medical review. CMS may implement “gold-carding” for highly compliant providers to lower the burden.
Specialty medications (buy-and-bill drugs covered by medical benefits) are high-spend, high-scrutiny and already subject to intense utilization management in commercial and MA markets. If CMS concludes WISeR “works,” the next logical frontier for “enhanced” prior auth in FFS would be drug categories that drive outsized spend—even though those are precisely the therapies where access delays can be clinically harmful. That’s why patient access advocates are paying close attention now: today’s procedure list may be contained, but the governance model, incentives, and AI-assisted decisioning could be applied to a more expansive list of medical benefit procedures and medications in a future phase. As CMS notes, the model may add participants, regions, and/or services over time.
SamaCare supports rigorous and well thought out efforts to reduce low-value care while protecting access to necessary treatment. But any PA model—especially one that incentivizes technology partners based on denials of care —must prove it doesn’t delay or deny clinically appropriate care or unduly overburden providers. Based on our experience as a technology provider that has helped resolve over 1M prior authorizations, AI is most powerful when it augments human expertise, clarifies policies up front, and prevents avoidable denials—not when it becomes a black box gate that patients and providers are forced to appeal after the fact.
Bottom line for patient access: WISeR’s launch slate is select procedures—not buy-and-bill drugs—for now. But the model’s architecture makes an expansion to specialty meds plausible if the test is deemed successful. Access teams should prepare playbooks to equally empower providers to leverage technology for evidence capture, policy alignment, and rapid appeals, while advocating for transparent AI, clinician-final review, and strict timeliness to keep the focus on getting patients the care their doctors prescribe.
CMS’s Wasteful and Inappropriate Service Reduction (WISeR) Model brings AI-augmented prior authorization into Traditional Medicare across six states (AZ, NJ, OH, OK, TX, WA) starting Jan 1, 2026. It targets a defined list of procedures deemed vulnerable to low-value use or fraud, does not change Medicare coverage rules, and currently excludes inpatient, emergency services, and services that would pose substantial risk if delayed. CMS will contract with third party companies to test utilizing AI to process prior authorizations for select procedures. Contracted companies will be paid a share of “savings” tied to reduced spending—creating real concerns about delays/denials and added provider burden. While buy-and-bill drugs are not included at launch, if WISeR is adopted, the logic that drives utilization controls will almost certainly extend to specialty medications, where patient access barriers already harm outcomes.
WISeR is a six-year CMS Innovation Center test that uses enhanced technologies (including AI/ML) to process prior authorizations for a subset of outpatient services in Traditional Medicare. CMS will contract with organizations that already manage prior authorizations for other payers and those companies will apply their technology to assess requests against existing Medicare coverage rules. Coverage policies themselves do not change under WISeR.
Where/when: WISeR runs Jan 1, 2026 – Dec 31, 2031 in AZ, NJ, OH, OK, TX, WA (one participant per MAC jurisdiction).
What’s included at launch: An initial list of procedures (ex. electrical nerve stimulators; knee arthroscopy for OA; skin/tissue substitutes), chosen for patient-safety and low-value-care concerns. Inpatient-only and emergency services are excluded, and CMS emphasizes licensed clinicians must determine non-payment decisions. Buy-and-bill drugs are not listed in the initial set.
Provider options: Providers can submit prior auth to the participant (or via the MAC), or skip PA and face pre-payment medical review. CMS may implement “gold-carding” for highly compliant providers to lower the burden.
Specialty medications (buy-and-bill drugs covered by medical benefits) are high-spend, high-scrutiny and already subject to intense utilization management in commercial and MA markets. If CMS concludes WISeR “works,” the next logical frontier for “enhanced” prior auth in FFS would be drug categories that drive outsized spend—even though those are precisely the therapies where access delays can be clinically harmful. That’s why patient access advocates are paying close attention now: today’s procedure list may be contained, but the governance model, incentives, and AI-assisted decisioning could be applied to a more expansive list of medical benefit procedures and medications in a future phase. As CMS notes, the model may add participants, regions, and/or services over time.
SamaCare supports rigorous and well thought out efforts to reduce low-value care while protecting access to necessary treatment. But any PA model—especially one that incentivizes technology partners based on denials of care —must prove it doesn’t delay or deny clinically appropriate care or unduly overburden providers. Based on our experience as a technology provider that has helped resolve over 1M prior authorizations, AI is most powerful when it augments human expertise, clarifies policies up front, and prevents avoidable denials—not when it becomes a black box gate that patients and providers are forced to appeal after the fact.
Bottom line for patient access: WISeR’s launch slate is select procedures—not buy-and-bill drugs—for now. But the model’s architecture makes an expansion to specialty meds plausible if the test is deemed successful. Access teams should prepare playbooks to equally empower providers to leverage technology for evidence capture, policy alignment, and rapid appeals, while advocating for transparent AI, clinician-final review, and strict timeliness to keep the focus on getting patients the care their doctors prescribe.
CMS’s Wasteful and Inappropriate Service Reduction (WISeR) Model brings AI-augmented prior authorization into Traditional Medicare across six states (AZ, NJ, OH, OK, TX, WA) starting Jan 1, 2026. It targets a defined list of procedures deemed vulnerable to low-value use or fraud, does not change Medicare coverage rules, and currently excludes inpatient, emergency services, and services that would pose substantial risk if delayed. CMS will contract with third party companies to test utilizing AI to process prior authorizations for select procedures. Contracted companies will be paid a share of “savings” tied to reduced spending—creating real concerns about delays/denials and added provider burden. While buy-and-bill drugs are not included at launch, if WISeR is adopted, the logic that drives utilization controls will almost certainly extend to specialty medications, where patient access barriers already harm outcomes.
WISeR is a six-year CMS Innovation Center test that uses enhanced technologies (including AI/ML) to process prior authorizations for a subset of outpatient services in Traditional Medicare. CMS will contract with organizations that already manage prior authorizations for other payers and those companies will apply their technology to assess requests against existing Medicare coverage rules. Coverage policies themselves do not change under WISeR.
Where/when: WISeR runs Jan 1, 2026 – Dec 31, 2031 in AZ, NJ, OH, OK, TX, WA (one participant per MAC jurisdiction).
What’s included at launch: An initial list of procedures (ex. electrical nerve stimulators; knee arthroscopy for OA; skin/tissue substitutes), chosen for patient-safety and low-value-care concerns. Inpatient-only and emergency services are excluded, and CMS emphasizes licensed clinicians must determine non-payment decisions. Buy-and-bill drugs are not listed in the initial set.
Provider options: Providers can submit prior auth to the participant (or via the MAC), or skip PA and face pre-payment medical review. CMS may implement “gold-carding” for highly compliant providers to lower the burden.
Specialty medications (buy-and-bill drugs covered by medical benefits) are high-spend, high-scrutiny and already subject to intense utilization management in commercial and MA markets. If CMS concludes WISeR “works,” the next logical frontier for “enhanced” prior auth in FFS would be drug categories that drive outsized spend—even though those are precisely the therapies where access delays can be clinically harmful. That’s why patient access advocates are paying close attention now: today’s procedure list may be contained, but the governance model, incentives, and AI-assisted decisioning could be applied to a more expansive list of medical benefit procedures and medications in a future phase. As CMS notes, the model may add participants, regions, and/or services over time.
SamaCare supports rigorous and well thought out efforts to reduce low-value care while protecting access to necessary treatment. But any PA model—especially one that incentivizes technology partners based on denials of care —must prove it doesn’t delay or deny clinically appropriate care or unduly overburden providers. Based on our experience as a technology provider that has helped resolve over 1M prior authorizations, AI is most powerful when it augments human expertise, clarifies policies up front, and prevents avoidable denials—not when it becomes a black box gate that patients and providers are forced to appeal after the fact.
Bottom line for patient access: WISeR’s launch slate is select procedures—not buy-and-bill drugs—for now. But the model’s architecture makes an expansion to specialty meds plausible if the test is deemed successful. Access teams should prepare playbooks to equally empower providers to leverage technology for evidence capture, policy alignment, and rapid appeals, while advocating for transparent AI, clinician-final review, and strict timeliness to keep the focus on getting patients the care their doctors prescribe.
CMS’s Wasteful and Inappropriate Service Reduction (WISeR) Model brings AI-augmented prior authorization into Traditional Medicare across six states (AZ, NJ, OH, OK, TX, WA) starting Jan 1, 2026. It targets a defined list of procedures deemed vulnerable to low-value use or fraud, does not change Medicare coverage rules, and currently excludes inpatient, emergency services, and services that would pose substantial risk if delayed. CMS will contract with third party companies to test utilizing AI to process prior authorizations for select procedures. Contracted companies will be paid a share of “savings” tied to reduced spending—creating real concerns about delays/denials and added provider burden. While buy-and-bill drugs are not included at launch, if WISeR is adopted, the logic that drives utilization controls will almost certainly extend to specialty medications, where patient access barriers already harm outcomes.
WISeR is a six-year CMS Innovation Center test that uses enhanced technologies (including AI/ML) to process prior authorizations for a subset of outpatient services in Traditional Medicare. CMS will contract with organizations that already manage prior authorizations for other payers and those companies will apply their technology to assess requests against existing Medicare coverage rules. Coverage policies themselves do not change under WISeR.
Where/when: WISeR runs Jan 1, 2026 – Dec 31, 2031 in AZ, NJ, OH, OK, TX, WA (one participant per MAC jurisdiction).
What’s included at launch: An initial list of procedures (ex. electrical nerve stimulators; knee arthroscopy for OA; skin/tissue substitutes), chosen for patient-safety and low-value-care concerns. Inpatient-only and emergency services are excluded, and CMS emphasizes licensed clinicians must determine non-payment decisions. Buy-and-bill drugs are not listed in the initial set.
Provider options: Providers can submit prior auth to the participant (or via the MAC), or skip PA and face pre-payment medical review. CMS may implement “gold-carding” for highly compliant providers to lower the burden.
Specialty medications (buy-and-bill drugs covered by medical benefits) are high-spend, high-scrutiny and already subject to intense utilization management in commercial and MA markets. If CMS concludes WISeR “works,” the next logical frontier for “enhanced” prior auth in FFS would be drug categories that drive outsized spend—even though those are precisely the therapies where access delays can be clinically harmful. That’s why patient access advocates are paying close attention now: today’s procedure list may be contained, but the governance model, incentives, and AI-assisted decisioning could be applied to a more expansive list of medical benefit procedures and medications in a future phase. As CMS notes, the model may add participants, regions, and/or services over time.
SamaCare supports rigorous and well thought out efforts to reduce low-value care while protecting access to necessary treatment. But any PA model—especially one that incentivizes technology partners based on denials of care —must prove it doesn’t delay or deny clinically appropriate care or unduly overburden providers. Based on our experience as a technology provider that has helped resolve over 1M prior authorizations, AI is most powerful when it augments human expertise, clarifies policies up front, and prevents avoidable denials—not when it becomes a black box gate that patients and providers are forced to appeal after the fact.
Bottom line for patient access: WISeR’s launch slate is select procedures—not buy-and-bill drugs—for now. But the model’s architecture makes an expansion to specialty meds plausible if the test is deemed successful. Access teams should prepare playbooks to equally empower providers to leverage technology for evidence capture, policy alignment, and rapid appeals, while advocating for transparent AI, clinician-final review, and strict timeliness to keep the focus on getting patients the care their doctors prescribe.
