The Centers for Medicare & Medicaid Services (CMS) has introduced a new model to address wasteful and inappropriate services in Original Medicare. The Wasteful and Inappropriate Service Reduction (WISeR) Model aims to ensure beneficiaries receive necessary care while protecting federal taxpayer dollars. CMS will collaborate with technology companies to test an improved prior authorization process, enhancing the existing system.
"CMS is committed to crushing fraud, waste, and abuse, and the WISeR Model will help root out waste in Original Medicare," said CMS Administrator Dr. Mehmet Oz. The model seeks to modernize Medicare by using technology alongside experienced clinicians to streamline prior authorization processes.
Wasteful healthcare services can account for up to 25% of spending in the U.S., with $5.8 billion spent on low-benefit services in 2022 alone, according to the Medicare Payment Advisory Commission. Abe Sutton, Director of the CMS Innovation Center, noted that such services offer minimal benefit and can lead to physical harm and psychological stress.
The WISeR Model will test whether technologies like artificial intelligence can expedite prior authorization for items prone to fraud or misuse, such as skin substitutes and knee arthroscopy for osteoarthritis. The model excludes inpatient-only and emergency services.
Participating companies will operate in specific regions with qualified clinicians making final coverage decisions. Payments will be based on reducing unnecessary services and improving decision-making speed without altering Medicare coverage criteria.
Providers in designated regions can submit prior authorization requests directly or through their Medicare Administrative Contractor. A future pathway may exempt compliant providers from WISeR review, focusing efforts on high-risk areas.
The WISeR Model does not affect those enrolled in Medicare Advantage. CMS has issued a Request for Applications for interested companies. More information is available on the CMS website and Federal Register.
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