CMS Releases FAQ on the New WiSeR Model

Following its announcement of the Wasteful and Inappropriate Service Reduction (WISeR) Model, the Centers for Medicare & Medicaid Services (CMS) released an FAQ page, thirteen items as of August 12, 2025. The FAQs address implementation details, guardrails, and expected impacts on patient safety, data privacy, and Medicare savings. They also cover participant compensation and the denial and appeals pathway, and note how the WISeR Model aligns with CMS and HHS leadership commitments to improve prior authorization.

Participant Compensation And Safeguards

Model participants, who use AI-assisted tools to review targeted services, are paid as a percentage of the savings their reviews generate. Any potential denial must be reviewed by a human clinician; AI alone cannot deny a claim. CMS will audit participant decisions against Medicare coverage criteria, assign quality scores, and may levy financial penalties or remove participants from the model for high inaccuracy.

Prior Authorization Non-Affirmation

If a prior authorization request is non-affirmed or denied, the provider or supplier may resubmit an unlimited number of times at the participant’s processing expense. Providers and suppliers may still furnish the service and submit a claim to the Medicare Administrative Contractor (MAC). The MAC may approve or deny the claim. A denial constitutes an initial payment determination and is subject to existing administrative appeal processes for providers, suppliers, and people with Medicare.

Timeline And Scope

The WISeR Model is scheduled for a six-year launch beginning January 1, 2026, in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington.