Neil Patil and Jack Hoadley
In June, the Centers for Medicare & Medicaid Services (CMS) announced a new six-year Innovation Center model called the Wasteful and Inappropriate Service Reduction (WISeR) Model. The model establishes new prior authorization requirements for a subset of items and services in Traditional Medicare. Under the model, CMS will partner with companies with experience managing prior authorization processes, including either utilization management contractors, or Medicare Advantage (MA) plans who can apply to be model participants.
WISeR will test the use of enhanced technologies, including artificial intelligence (AI), for prior authorizations on the designated services, beginning on January 1, 2026, in select states. The services are those that CMS has determined may pose patient safety concerns and may involve prior reports of fraud, waste, and abuse. CMS officials noted, during a public webinar, that the model’s subset of services represented $1.9-5.8 billion in spending on low-value care in 2022.
The proposed initiative is a major shift, as most traditional Medicare benefits do not require prior authorization. However, nearly all MA plans require prior authorization for some services. There is widespread recognition that prior authorization can be effective in reducing unnecessary, duplicate, harmful or “low-value” care, where the harms or costs outweigh the benefit. Conversely, prior authorization can result in denials of or delays in necessary and even critical care, as well as lead to costly out-of-pocket medical expenses when a patients receive services that are denied by their health plans after the fact. This blog takes lessons learned from use of prior authorization in MA and applies them to the new WISeR model.
Potential for Delays or Denials of Appropriate Care
Some MA plans have been criticized for inappropriately using prior authorization to delay or deny care. This has resulted in MA enrollees not receiving basic Medicare benefits to which they are entitled. In recent years, CMS has made regulatory changes to alleviate these issues, including clarifying that MA plans must cover the same benefits as traditional Medicare and setting guardrails on plans’ internal clinical decision making.
It remains unclear if these new requirements will reduce inappropriate use of prior authorization by MA plans. CMS plans to monitor WISeR model participants and measure performance based on metrics, including the accuracy and promptness of prior authorization decisions, providers’ experience with the process, and impacts on quality of care for beneficiaries. The CMS monitoring strategy will also follow principles aimed at protecting beneficiaries from harm and ensuring compliance with applicable Medicare regulations. CMS has posted the preliminary list of items and services subject to prior authorization under the model, but it is not clear how CMS determined that the services are deemed as low-value.
Policymakers and stakeholders should consider key questions to ensure Medicare beneficiaries receive appropriate access to timely benefits under the WISeR model:
- How will CMS ensure that model participants comply with national coverage determinations, local coverage determinations, and general Medicare coverage and benefit conditions?
- Will quality measures adequately assess model participant performance?
- Will continuity of care requirements apply under the WISeR model?
- MA regulations require a 90-day transition that prohibits prior authorizations for new MA enrollees undergoing active treatment
- Does the WISeR model list of services accurately capture the appropriate subset of “low-value” services?
- Policymakers should review other studies of low-value care, including a recent Medicare Payment Advisory Commission (MedPAC) report that lists potential low-value services.
Beneficiary Protections and Appeals Rights
Medicare Advantage has a set of disclosure requirements and appeals rights to ensure that use of prior authorization by MA plans is managed in a way that protects plan enrollees. In 2023, 11.7 percent of care denials were appealed by MA enrollees and nearly 82 percent of appeals resulted in a decision that was favorable to the enrollee.
While CMS notes that the WISeR model would maintain applicable appeal rights for beneficiaries, it is unclear if MA regulations around disclosure requirements or appeal rights would apply to MA. For instance, will MA regulations require a 90-day transition, which prohibits prior authorizations for new MA enrollees undergoing active treatment, apply to Medicare beneficiaries under the model? Policymakers and stakeholders should consider whether adequate safeguards are in place so beneficiaries understand why a service is denied and are aware of their appeal rights.
Potential for Provider Burden and Providers Exiting Traditional Medicare
Studies show that prior authorization and the need to support appeals make administrative burdens in MA far higher than in traditional Medicare. In one study, 90 percent of medical group practices reported that prior authorization was very or extremely burdensome—a contributing factor to increasing exits of providers and health systems from MA contracts.
Policymakers and stakeholders should consider key factors to ensure that the WISeR model does not lead to greater provider frustration from administrative burdens:
- Should decision timeframes required under the model mirror current MA requirements to provide decisions within 14 days for standard requests or 72 hours for expedited requests?
- What paperwork will be required for providers targeted under the model?
- Will prior authorization denials come with a specific reason, as required in MA?
Artificial Intelligence
CMS announced that the WISeR Model will test enhanced technologies, including AI, in the proposed prior authorization decisions. MA plans have increasingly used AI models in prior authorization, with some plans arguing that AI is an aid in clinical decision making and automates administrative tasks to reduce provider burdens. However, others contend that MA prior authorization decisions have been made solely by AI tools and decry a lack of transparency.
Some reports have found that using AI can lead to high denial rates and worsen health disparities, given that AI algorithms trained on data that reflect existing biases will perpetuate them.
Policymakers and stakeholders should consider key issues to ensure that enhanced technologies and AI under the WISeR model are not used inappropriately:
- Will there be adequate guardrails on use of AI to make decisions?
- Will a clinician make the final decision if the prior authorization is denied, similar to current MA regulations?
- How will CMS ensure that underlying AI algorithms used in the model ensure equitable coverage and consider beneficiaries’ individual circumstances, such as required under current MA regulations?
- How will CMS ensure that the AI algorithms used in the model are transparent for beneficiaries and stakeholders?
Conclusion
Given the proliferation of prior authorization in MA, there are many factors that CMS, policymakers, and stakeholders should consider as the WISeR model establishes new prior authorization requirements in traditional Medicare—including potential denials and delays of care, beneficiary awareness, appeals rights, provider burden, and AI concerns. Since MA plans may be selected as model participants, considerations should also include whether their participation is a conflict of interest, given that MA plans could benefit if more traditional Medicare beneficiaries are denied services. Transparency may be one way CMS could alleviate these issues, including by publicly reporting prior authorization metrics under the program, similar to the requirements in MA, as well as publishing the list of model participants.
Editor’s Note (Update – August 2025):
Since the publication of this post, CMS has released a WISeR Model Frequently Asked Questions document that clarifies some of the questions raised in this blog. Key clarifications from CMS include additional information on how services were selected, beneficiary protections and appeal rights, oversight of the model, as well as the prior authorization decision timeframes under the model. Additionally, in late July, Reps. Alexandria Ocasio-Cortez (NY-14) and Lloyd Doggett (TX-37), along with 40 colleagues, sent a letter to CMS urging the agency to halt implementation of the WISeR model. The letter acknowledged the cost-saving intentions of the model, but vocalized concern over the use of for-profit companies as model participants and lessons learned from the inappropriate use of prior authorization in MA.