/>iCMS recently announced a new model it will be using to pilot the use of artificial intelligence and machine learning in reviewing prior authorizations submitted for certain services CMS has identified as being at greater risk of fraud, waste, or abuse, which includes electrical nerve stimulators, knee arthroscopy for osteoarthritic knees, and skin and tissue substitutes (where existing LCDs apply). The new Wasteful and Inappropriate Service Reduction (WISeR) Model is scheduled to launch its six-year term on January 1, 2026, in six selected states (Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington). For the duration of the model, providers and suppliers (e.g., hospitals, physicians, and other providers) will be required to submit prior authorizations for the specified items and services unless they wish to complete a post-service/pre-payment medical review.
The inspiration for this model comes from the Medicare Advantage (MA) space, where research conducted by CMS showed significant reductions in the decision time to prior authorization determination, particularly for affirmed prior authorization requests, with some MA contractors experiencing almost instantaneous decision time for prior authorization requests for services with very clear clinical coverage. As part of its attempt to mimic the perceived successes from the MA arena, CMS is seeking applications from companies that have “expertise managing the prior authorization process for other payers using enhanced technology like AI.” However, it’s typical for post-service/pre-payment medical reviews to delay payment and create risk for patients and providers in that the claim can be denied even after providing the service.
The specific types of items or services designated as subject to the prior authorization process were not selected by coincidence, as CMS has scrutinized many of these in the past. CMS specifically stated that they considered which services have been defined as low-value under current research, what services and items are already subject to prior authorization in MA plans, and reports of fraud, waste and abuse from OIG, DOJ, and other sources when determining which services to include as part of the model.
CMS also mentions in their Notice that they may be considering implementing “gold carding,” where compliant providers will be exempted from the utilization review requirements (i.e., the prior authorization and post-service/pre-payment review). CMS appears to be considering a prior authorization rate of at least 90% to be eligible for gold carding, which CMS believes demonstrates the provider has a sufficient understanding of the requirements for submitting an accurate claim.
It is important to note that the “model participants” (e.g., the companies providing the prior authorization services) might be paid on a share of averted expenses. But, CMS’s stated goal of the WISeR model is to also test: “the speed and accuracy of new technology-assisted decision-making; WISeR participants’ ability to help patients navigate away from low-value or potentially unsafe treatments and towards clinically appropriate higher-value care through provider/supplier education;… and potential alignment with Medicare Advantage.”
Providers that may be impacted by the WISeR model should monitor the CMS website including the webpage dedicated to the WISeR model, their applicable Medicare Administrative Contractor (MAC) webpages and educational postings for further information.
Find the CMS Press Release Here.
