CMS Launches WISeR Model Explained for Providers

The Centers for Medicare and Medicaid Services (CMS) introduced a significant new audit program on January 01, 2026, which is called the Wasteful and Inappropriate Service Reduction (WISeR) Model.

The goal of WISeR is straightforward. CMS aims to reduce wasteful and low-value care by focusing on a limited list of Medicare-covered services that have been, or are at risk of becoming, vulnerable to fraud, waste, or abuse. Instead of reviewing everything broadly, WISeR concentrates on a specific set of services and uses technology-supported workflows, including artificial intelligence (AI), to review claims before Medicare pays.

To do this, WISeR relies on two review methods:

• Prior authorization, or
• Pre-payment medical review

Authorized WISeR participants handle both processes, which CMS has formally outlined. Below is a clear explanation of how the model works and what providers should expect.

How Does the WISeR Model Work?

Under WISeR, providers and suppliers (referred to here as Providers) located in six participating states must follow new coverage approval steps before payment is issued for selected items and services. The six states are:

Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington.

Providers must use one of the following two routes to receive a coverage decision for WISeR-selected services:

• Prior Authorization completed by an approved WISeR participant
• Pre-Payment Medical Review conducted by an approved WISeR participant

CMS explains these pathways in its official WISeR infographic.

WISeR applies to services performed in four common care settings:

• Hospital outpatient departments
• Ambulatory surgery centers
• Home settings
• Office locations

The services included in WISeR are generally elective or planned procedures that already have clear Medicare coverage rules available through sources such as Medicare laws, regulations, National Coverage Determinations (NCDs), and Local Coverage Determinations (LCDs).

Which Services Are Included Under WISeR?

CMS has identified multiple categories of services for review under this model. These include:

• Electrical nerve stimulators
• Sacral nerve stimulation for urinary incontinence
• Phrenic nerve stimulator
• Induced lesions of nerve tracks
• Epidural steroid injections are used for pain management
• Percutaneous vertebral augmentation
• Debridement for osteoarthritic knee conditions
• Hypoglossal nerve stimulation for obstructive sleep apnea
• Incontinence control devices
• Diagnosis and treatment of impotence
• Percutaneous image-guided lumbar decompression for spinal stenosis
• Skin and tissue substitutes

A key difference with WISeR is that technology companies, not healthcare providers, serve as the main participants in the model. These companies test advanced systems like AI and machine-learning tools to support prior authorization decisions and pre-payment review determinations.

Who Participates in WISeR, and How Are They Paid?

CMS has chosen six technology firms as WISeR “model participants.” CMS describes these participants as companies with proven experience managing prior authorizations using enhanced technology for other payer systems, including Medicare Advantage.

Even though Medicare Administrative Contractors (MACs) will still operate in their usual roles, the WISeR participants will handle the actual work tied to:

• Prior authorization decisions
• Pre-payment medical reviews

These WISeR participants earn incentive payments based on a percentage of savings achieved through reduced spending under the model. CMS has stated that the payment approach is intended to encourage accurate decisions, fast turnaround times, and clearer communication rather than driving denials.

CMS also plans to actively track denial activity. If a participant shows poor performance or quality issues, CMS may lower their payments or remove them from the model entirely.

When Did WISeR Begin?

WISeR began officially on January 01, 2026. On January 05, 2026, the WISeR participants started to accept submissions of prior authorization.

These prior authorization requests apply to services performed on or after January 15, 2026. CMS also released updated FAQs that address the operational readiness of WISeR electronic portals.

Important Note About WISeR Billing Codes

The WISeR Provider and Supplier Operational Guide includes two critical appendices:

• Appendix A lists the items and services subject to prior authorization or pre-payment medical review.
• Appendix B lists “associated” codes linked to the primary WISeR services.

Associated codes in Appendix B do not require prior authorization if the primary service was properly submitted and approved. However, those related codes may still be denied in cases where:

• The primary service was not affirmed through prior authorization, or
• The claim was denied after review

CMS indicates that associated codes should only be flagged when a related primary code appears on the claim and that primary code was not affirmed.

Is WISeR Truly “Voluntary”?

For Providers, the practical answer is no.

CMS refers to WISeR as “voluntary,” but that label appears to apply only to the technology companies participating in the model. Providers in the impacted states are not able to opt out.

Providers must either:

• Submit a prior authorization request for WISeR services, or
• Submit a claim normally and allow the MAC to route it for pre-payment review

CMS has also mentioned it may explore a future gold carding approach, which could exempt Providers from prior authorization if they consistently receive high affirmation rates.

Key Takeaways for Providers

Providers operating in WISeR states should prepare for increased documentation expectations and tighter controls on selected services.

Key points include:

• Providers in the affected states must pursue prior authorization through WISeR participants or risk pre-payment medical review.
• Appeals are only available after the service is performed and a claim is submitted following a non-affirmed prior authorization decision or a pre-payment denial.
• In the past, contingency-style audit incentives have led to higher denial rates and major appeal backlogs, and similar strain could occur again if denial patterns rise under WISeR.
• A bill titled H.R. 6361, the “Ban AI Denials in Medicare Act,” was introduced on December 02, 2025, and proposes blocking WISeR and similar models that test prior authorization under traditional Medicare, including those using AI tools. If passed as written, it could eliminate the WISeR model entirely.