{"id":34897,"date":"2025-07-24T23:25:12","date_gmt":"2025-07-24T23:25:12","guid":{"rendered":"https:\/\/www.newsbeep.com\/us\/34897\/"},"modified":"2025-07-24T23:25:12","modified_gmt":"2025-07-24T23:25:12","slug":"wiser-model-will-test-the-use-of-artificial-intelligence-for-prior-authorization-in-medicare-key-considerations-for-health-care-providers-and-suppliers-mintz-health-care-viewpoints","status":"publish","type":"post","link":"https:\/\/www.newsbeep.com\/us\/34897\/","title":{"rendered":"WISeR Model Will Test the Use of Artificial Intelligence for Prior Authorization in Medicare: Key Considerations for Health Care Providers and Suppliers | Mintz – Health Care Viewpoints"},"content":{"rendered":"

The Center for Medicare and Medicaid Innovation (CMMI) recently announced<\/a> a six-year payment model for 2026-2031 called the Wasteful and Inappropriate Service Reduction (WISeR) Model. WISeR will test the use of artificial intelligence and machine learning (AI\/ML) for prior authorization and pre-payment review processes for certain items and services provided to beneficiaries in Medicare Fee-for-Service (Medicare FFS) (otherwise known as Original Medicare). According to CMMI, WISeR is intended to reduce unnecessary or low-value services, which aligns with CMMI\u2019s new strategic direction under the Trump Administration<\/a>.\u00a0<\/p>\n

Although CMMI touts the payment model as a voluntary initiative, health care providers and suppliers must comply with WISeR\u2019s prior authorization and pre-payment review processes in the six states where WISeR will be rolled out. Prior authorization processes have been the subject of widespread concern given that they arguably financially incentivize payers and their vendors to deny health care items and services ordered by health care providers.<\/a> WISeR implements these financial incentives for participating technology companies through a shared savings model (i.e., the technology companies receive a percentage of the savings attributed to their prior authorization and pre-payment review processes). This blog post outlines key considerations for health care providers and suppliers to prepare for WISeR, which becomes effective January 1, 2026.\u00a0<\/p>\n

Overview of WISeR<\/p>\n

WISeR is unique because, unlike CMMI\u2019s other payment models where participants are accountable care organizations and health care providers, participants in WISeR will be technology companies with AI\/ML solutions and experience managing the prior authorization process for payers, including Medicare Advantage plans. WISeR participants will conduct prior authorization and pre-payment reviews, supported by AI\/ML tools that are expected to streamline those processes. Standard decisions are expected within seven calendar days and expedited decisions within two calendar days. WISeR also requires final review of denial decisions by licensed clinicians as a backstop.<\/p>\n

Payments to WISeR participants will be a percentage of the savings attributed to the participant\u2019s review activities under the model. However, these payments will be contingent on the participants meeting certain performance metrics related to accuracy, processing times, provider\/supplier experience, and impacts on quality of care for beneficiaries. CMMI also requires the participants to report data metrics on their prior authorization process, including the number of approvals versus denials, the time taken to reach decisions, and the number of appeals of an initial determination.\u00a0<\/p>\n

Scope of WISeR<\/p>\n

CMMI describes WISeR as a voluntary initiative, but the model is mandatory for providers in the states where WISeR will operate \u2013 Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. These six states were selected based on Medicare volume and alignment with Medicare Administrative Contractor jurisdictions.\u00a0<\/p>\n

Initially, WISeR targets specific health care procedures and medical devices, although CMMI is clear that this list of procedures and devices subject to WISeR may evolve over time. Currently included in the model are:\u00a0<\/p>\n

\tCertain stimulator services (e.g., electrical nerve, deep brain stimulation for Essential Tremor and Parkinson\u2019s Disease; vagus nerve stimulation);
\n\tInduced Lesions of nerve tracts;
\n\tEpidural steroid injections or pain management;
\n\tPercutaneous vertebral augmentation for vertebral compression fracture;
\n\tCervical fusion;
\n\tArthroscopic knee procedures; and
\n\tHypoglossal nerve stimulation for obstructive sleep apnea;
\n\tIncontinence control devices;
\n\tDiagnosis and treatment of impotence;\u00a0
\n\tPercutaneous lumbar decompression for lumbar spinal stenosis; and
\n\tCertain skin and tissue substitutes.\u00a0<\/p>\n

Provider Requirements\u00a0<\/p>\n

Providers and suppliers of applicable services\/devices in the six selected states will be affected by WISeR\u2019s prior authorization and pre-payment review processes. Of note, providers and suppliers are not required to submit a prior authorization request. If they opt not to do so, however, the claim for the items or services is subject to pre-payment medical review where the WISeR participant may request additional documentation to support the necessity of the care. Under the pre-payment review process, the provider or supplier runs the risk of a denied claim after the item or service has already been furnished, and the process could potentially take a few months before a decision is made, delaying payment.<\/p>\n

CMMI is also considering \u201cgold carding,\u201d which would exempt providers and suppliers from the prior authorization and pre-payment review processes if at least 90% of the provider or supplier\u2019s claims submitted through the prior review process are favorable during a periodic assessment.<\/p>\n

Considerations for Health Care Providers and Suppliers<\/p>\n

In anticipation of the expanded use of prior authorization and pre-payment processes in Medicare FFS under WISeR, providers and suppliers of the targeted services (particularly in the six states where WISeR will operate) should review their current use of these services. Further, providers should consider training for clinical staff to ensure clinicians understand which services and items are affected and how to document medical necessity sufficiently and in a manner that aligns with existing Medicare coverage criteria. Coding and billing teams will likely need to be trained on submission protocols specific to WISeR, including whether the provider opts to submit certain items for prior authorization review or undergo pre-payment review. Compliance departments should also consider training on the new review processes and how to respond to denials or requests for additional information.\u00a0<\/p>\n

[View source<\/a>.]<\/p>\n","protected":false},"excerpt":{"rendered":"The Center for Medicare and Medicaid Innovation (CMMI) recently announced a six-year payment model for 2026-2031 called the…\n","protected":false},"author":2,"featured_media":34898,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[45],"tags":[182,181,507,74],"class_list":["post-34897","post","type-post","status-publish","format-standard","has-post-thumbnail","category-artificial-intelligence","tag-ai","tag-artificial-intelligence","tag-artificialintelligence","tag-technology"],"_links":{"self":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/posts\/34897","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/comments?post=34897"}],"version-history":[{"count":0,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/posts\/34897\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/media\/34898"}],"wp:attachment":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/media?parent=34897"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/categories?post=34897"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/tags?post=34897"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}