Chart demonstrates latest changes in prescription authorization criteria within traditional Medicare, as tested by the Centers for Medicare & Medicaid Services

The Centers for Medicare and Medicaid Services (CMS) has announced the launch of a new pilot program called the Wasteful and Inappropriate Service Reduction (WISeR) Model. This initiative, set to begin in 2026 and run through 2031, marks a significant shift in CMS's approach to managing utilization in Traditional Medicare.

The WISeR Model introduces a new workflow for providers in the six pilot states, which have yet to be identified. Unlike traditional Medicare Administrative Contractors, CMS will partner with technology companies in this program.

The primary focus of the WISeR Model is on services considered vulnerable to waste and abuse. The pilot program will test prior authorization requirements for 17 specific services, aiming to reduce unnecessary healthcare expenditures and improve the quality of care.

In 2023, Medicare Advantage plans processed more than 100 times as many prior authorization requests as Traditional Medicare, highlighting the need for a more effective system in Traditional Medicare.

Under the WISeR Model, providers in the pilot states can choose between submitting a pre-service prior authorization request or undergoing a post-service pre-payment review for the targeted services. This flexibility allows for a more efficient and less burdensome process for providers.

In addition to prior authorization requirements, the pilot program will also incorporate the use of pre-payment medical reviews. This approach will enable early detection and prevention of potentially inappropriate services, further enhancing the effectiveness of the WISeR Model.

The WISeR Model represents a progressive step towards more efficient and responsible healthcare management in Traditional Medicare. By partnering with technology companies and testing prior authorization requirements for 17 services, CMS aims to reduce waste, abuse, and improve the quality of care for Medicare beneficiaries.