Following discussions with major health insurers on their commitments, including a pledge to reduce the number of services requiring prior authorization, the Centers for Medicare & Medicaid Services announced its Wasteful and Inappropriate Service Reduction, or WISeR, model. This model aims to selectively implement prior authorization within traditional Medicare.

Under the WISeR model, participating organizations will include technology companies that currently manage the prior authorization process for other payers using tools such as artificial intelligence and machine learning. In designated states, these companies will utilize their enhanced technology to reduce low-value services that are frequently associated with fraud, waste, and abuse, while also streamlining the review process. The specific services currently include skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy for treating knee osteoarthritis.

What Does APTA Think of the Model?

Physical therapist services are currently not included under the WISeR model. APTA is closely monitoring the development and implementation of this model, as one of its goals is to apply commercial payer prior authorization processes to traditional Medicare for specific services. These processes have been known to be burdensome, lack transparency, and cause delays in care. The WISeR model is not expected to change payment criteria or Medicare coverage. One aspect of the model involves lowering spending in traditional Medicare, which is a factor in how participants are compensated. Additionally, model participants are expected to help alleviate the administrative burden on providers. 

Providers have the option of submitting prior authorization requests for services covered under the model, which is voluntary. If they choose not to submit a request for prior authorization, their claim will be subject to pre-payment medical review. Those who decide to submit a prior authorization request will do so directly to the model participants or their Medicare Administrative Contractor, which will then forward the request to the model participant. In the future, CMS may introduce a “gold carding” pathway that would allow providers and suppliers with strong compliance records to qualify for exemptions from WISeR review.

The model will run for six years beginning in 2026 in select regions. Applications for participants are due by July 25, 2025. View the model overview fact sheet to learn more.