WISeR brings prior authorization to traditional Medicare in 6 states

The WISeR model brings prior authorization to traditional Medicare, the part of the program where most services have never needed anyone’s permission in advance. Since January 1, under the Wasteful and Inappropriate Service Reduction (WISeR) model, clinicians in 6 states must either obtain prior authorization for 14 groups of services or accept a medical review of the claim before Medicare pays it.

The reviews are run by 6 technology companies, one per state, selected by the CMS Innovation Center. They are paid a share of the Medicare spending their reviews avert. CMS describes the model as a test of whether technology, including artificial intelligence, combined with clinical review can reduce payment for services that are often low value or vulnerable to misuse. Physician groups and members of Congress have objected, and the House Appropriations Committee voted in 2025 to block funding for it.

This analysis describes how WISeR works and how it differs from Medicare’s earlier prior authorization programs. It also compares the model with the rules that took effect for Medicare Advantage on the same day. Providers could begin submitting requests on January 5, for services furnished on or after January 15.

Key takeaways

• Traditional Medicare only, in 6 states. WISeR runs from January 1, 2026, through December 31, 2031. It does not apply to Medicare Advantage.
• Prior authorization or prepayment review. For the listed services, a provider can request prior authorization or skip it and accept a medical review of the claim before payment.
• Clinicians decide non-payment. CMS says recommendations for non-payment are made by appropriately licensed clinicians using standardized, evidence-based procedures.
• Vendors are paid from averted spending. Participants receive a share of the expenditures associated with care they avert, adjusted for performance, and face financial penalties for inappropriate denials.
• Faster clocks than Medicare Advantage. CMS says participants typically decide standard requests within 3 days and expedited requests within 2 days, compared with 7 days and 72 hours under the new federal limits for Medicare Advantage.
• Not Medicare’s first prior authorization program. Medicare administrative contractors already run prior authorization for certain outpatient services and medical equipment. WISeR is the first to hand the reviews to private technology companies paid from savings.

What WISeR covers

The CMS model page sets out the basic design. The model runs for 6 performance years. It applies to people with Original Medicare in the participating states and, in CMS’s words, will have no impact on people with Medicare Advantage. Beneficiaries keep their choice of provider. The model excludes emergency and inpatient-only services. It also excludes services that would pose a substantial risk to patients if delayed.

Each state has a single participant selected by the Innovation Center.

From the CMS WISeR provider fact sheet and FAQs.

A Congressional Research Service In Focus report from December 2025 notes that CMS chose the states so that each could be compared with non-model states in the same claims processing region, and that the model covers about 6.4 million beneficiaries.

The services were chosen because CMS considers them low value or vulnerable to fraud, waste and abuse. The WISeR provider fact sheet lists the first year’s services by the coverage policy that governs each.

From the CMS WISeR provider fact sheet. NCD means national coverage determination. Codes already subject to Medicare’s separate prior authorization program for certain hospital outpatient services are excluded.

The list has 2 features that matter. First, every service on it is governed by an existing Medicare coverage policy. WISeR does not create new coverage criteria. It adds a review step to check whether the criteria Medicare already applies are met before payment. Second, the services are delivered mostly in outpatient settings, from ambulatory surgery centers to physician offices. Inpatient care is outside the model.

How a request moves through the model

The fact sheet and CMS’s frequently asked questions describe the process.

1. The provider decides whether to request authorization. With the patient, the provider chooses between prior authorization and post-service, prepayment review.
2. The request goes to the state’s participant or to the Medicare administrative contractor (MAC). Either way, the participant performs the review.
3. The participant reviews it. A clinician conducts a peer-to-peer discussion if needed. CMS says participants typically decide within 3 days of receiving an initial or resubmitted request, or within 2 days when a delay could seriously jeopardize the beneficiary’s life or health.
4. The provider gets a tracking number. An affirmed request receives an affirmative unique tracking number generated by the MAC. A non-affirmed request receives a non-affirmative tracking number with a detailed rationale, and the provider may resubmit.
5. The claim follows. Claims for services that went through prior authorization carry the tracking number.

The prepayment route works differently. If a provider furnishes a listed service without prior authorization, the MAC flags the claim for medical review by the participant. The provider may submit documentation before the MAC approves or denies payment. If prior authorization was requested and not affirmed, and the provider furnishes the service anyway, the MAC denies the claim. That denial is an initial payment determination, which the provider or beneficiary can appeal through Medicare’s existing appeals process. CMS states that the model does not change provider payment amounts or appeal rights.

CMS also plans an exemption, often called gold carding. According to the FAQs, providers and suppliers that reach a set affirmation threshold will generally be exempt from further prior authorization and prepayment review for the selected services for a defined period before being re-evaluated. CMS planned to launch the exemption in 2026 but has not published the threshold.

What practices in model states can do now

The model’s documents translate into a short set of practical steps for practices that perform the listed services. These are this analysis’s reading, not CMS guidance.

• Confirm the patient’s coverage first. WISeR applies only to Original Medicare. A Medicare Advantage patient having the same procedure follows the plan’s rules instead.
• Choose the route case by case. Prior authorization gives an answer before the procedure. Prepayment review avoids a wait before care but leaves payment uncertain until after the service is delivered. For a scheduled procedure such as cervical fusion or a nerve stimulator implant, an answer before the operating room is usually worth a few days.
• Document against the governing policy. Because each service is tied to an existing NCD or LCD, the documentation a reviewer will look for is already written down. Building a request around that policy’s criteria is the most direct way to an affirmation.
• Keep the tracking number with the claim. A claim for an authorized service without its tracking number invites a review that the authorization was meant to prevent.
• Track non-affirmations. The detailed rationale on each non-affirmed request shows which documentation gaps recur, and the same records will matter when CMS sets its gold-card threshold.

How the vendors are paid

WISeR’s payment design is what separates it from almost every other prior authorization program in Medicare.

According to the model page, participants receive a percentage of the expenditures associated with wasteful or inappropriate care they avert, and the percentage is adjusted based on performance measures that include provider experience. The CRS report describes the payment as a percentage of the dollar value of denied requests, calculated after resubmissions have been adjudicated. The FAQs add 4 limits.

• Participants are paid only from a share of savings tied to their reviews.
• They are paid once per beneficiary, regardless of how many times a request is resubmitted.
• Audit results feed quality scores, which can reduce payment for inaccurate determinations.
• Participants are financially penalized for inappropriate denials, and those with high inaccuracy rates may be terminated.

The documents reviewed for this analysis do not state the percentage. An illustration shows why it matters anyway. Say the share were 10%, and a participant non-affirms a $20,000 procedure that, after resubmissions, is never performed or paid. The participant would earn $2,000 from that single case. An affirmation of the same request would earn it nothing. The audits and penalties exist to keep that asymmetry from shaping decisions, which is why their design, and how often they are applied, deserves as much scrutiny as the vendors’ technology.

The design creates a direct financial link between a vendor’s denials and its revenue, then tries to offset that link with audits and penalties. Whether the offsets are strong enough is the central empirical question of the model.

When the reviewer is paid from what it averts, the overturn rate is not a side statistic. It is the measure of whether the incentive is working as intended.

The design also differs from how risk works in Medicare Advantage. An MA plan that denies a service avoids paying for it, but the plan also bears the cost of the enrollee’s care over time and competes for enrollment. A WISeR participant bears none of the cost of care and does not compete for patients. Its revenue comes only from averted spending, net of penalties.

Medicare has run prior authorization before

WISeR is new in who does the reviewing and how they are paid, not in the idea of reviewing traditional Medicare services in advance. CMS’s page on prior authorization and pre-claim review initiatives lists 4 programs already running in fee-for-service Medicare.

• Prior authorization for certain hospital outpatient department services
• Prior authorization for repetitive, scheduled non-emergent ambulance transport
• Prior authorization for certain durable medical equipment and supplies
• Review Choice Demonstrations for home health and for inpatient rehabilitation facility services

Earlier initiatives covered power mobility devices and non-emergent hyperbaric oxygen.

Those programs share a structure. The page explains that under prior authorization, the provider gets a decision before rendering the service, while under pre-claim review the decision comes before the claim is submitted, even if the service was already delivered. In both, the MAC issues an affirmed or non-affirmed decision, and the initiatives do not change Medicare’s medical necessity or documentation requirements.

WISeR keeps the affirmation structure and the existing coverage criteria, and it changes 2 things. The reviews are performed by technology companies selected through an application process rather than by the MACs that already process Medicare claims. And the reviewers are paid from the spending they avert rather than under a standard contract. That history gives CMS a baseline. If WISeR’s affirmation rates and appeal outcomes differ from those of the MAC-run programs, the difference is the first evidence of what the new reviewer and payment model change.

How WISeR compares with Medicare Advantage

WISeR started on the same day the federal decision limits for Medicare Advantage and Medicaid took effect under the CMS Interoperability and Prior Authorization Final Rule. Rounds described those limits earlier this month. The 2 approaches differ in ways that matter to clinicians who see both kinds of patients.

Compiled from CMS’s WISeR model documents. Medicare Advantage features reflect the federal rules in effect for 2026.

The option to skip prior authorization deserves attention. In MA, a service that requires authorization cannot be paid without it. In WISeR, a provider who is confident the documentation supports the service can furnish it and accept a review before payment. That shifts risk to the provider, who has delivered the service before knowing whether Medicare will pay, but it also keeps the clinical decision with the clinician and the patient.

The pushback

Opposition began before the model started. According to the CRS report, members of Congress sent letters to CMS in August and September 2025 raising concerns and asking for information. Legislation was introduced in the House to prohibit WISeR’s implementation, and the House Appropriations Committee adopted an amendment to its fiscal 2026 Labor-HHS spending bill that would bar funding for the model if enacted.

The Medical Group Management Association wrote to the committee’s leaders on November 13, 2025, commending what it described as the unanimous adoption of that amendment. The letter argued that physicians’ experience with prior authorization in Medicare Advantage, including delayed care and administrative burden, should not be repeated in traditional Medicare. It said physician organizations were not consulted when the model was developed.

The CRS report summarizes the main concerns raised by providers and beneficiary advocates. Prior authorization could limit or delay beneficiaries’ access to care, and providers may face more denials and lost revenue. Clinicians and patients may also disagree with CMS’s classification of some services as low value. The report notes that the model could face litigation from providers or beneficiaries who are denied, or who did not consent to inclusion. Neither beneficiaries nor providers can opt out of the model, although providers can choose prepayment review instead of prior authorization.

The funding amendment would take effect only if it appears in an enacted appropriations law. Until then, the model runs.

What WISeR will be able to show

A model is a test, and this one has several things worth measuring.

Affirmation and overturn rates by participant. Each state has its own vendor. Comparing how often each affirms requests on first submission, and how often its non-affirmations are reversed on appeal, would show whether the vendors apply the same Medicare criteria the same way.

The split between prior authorization and prepayment review. If many providers choose prepayment review, the model becomes mostly a claims review program. If most choose prior authorization, it becomes a test of whether advance review changes ordering.

Utilization in model states compared with neighbors. CMS chose states so that each could be compared with non-model states in the same MAC region. That comparison is how CMS will estimate whether the model reduces use of the listed services, and whether any reduction comes from low-value care or from care that patients needed.

Effects on patients. Whether beneficiaries in model states wait longer for listed procedures, or forgo them, is the question the critics care about most. Answering it requires data on patients who did not receive a service, which claims alone do not capture.

Gold-card uptake. The number of providers who qualify for exemption, and how quickly, will indicate whether the model concentrates review on outliers or applies it broadly.

Time to decision in practice. CMS describes typical decisions within 3 days. Whether that holds for complex requests and resubmissions will matter to patients waiting for procedures such as cervical fusion or nerve stimulator implantation.

What to watch in 2026

Appropriations. Whether the House committee’s funding prohibition survives into an enacted spending law will decide whether the model continues past this year in its current form.

The gold-card threshold. CMS has said it will launch exemptions in 2026. The threshold it sets will shape how many providers stay in the review process.

Changes to the service list. The fact sheet notes that codes may change. Additions would expand the model’s reach. Removals could signal that some services were poor candidates.

Litigation. The CRS report flags the possibility of suits by providers or beneficiaries who are denied or who did not consent to inclusion. A challenge would test how far the Innovation Center’s model authority extends to adding review steps in traditional Medicare.

Published results. CMS has not said what interim data it will release. Participant-level affirmation and overturn data would allow the outside evaluation the model’s critics are asking for.

About this analysis

Basis. This analysis relies on CMS’s WISeR documents and its page on fee-for-service prior authorization initiatives. For the policy debate, we used the December 2025 version of the Congressional Research Service In Focus report on the model and the Medical Group Management Association’s November 2025 letter to House appropriators. Details of the House legislation and the appropriations amendment are described from those 2 documents, not from the legislative texts.

Data notes.

• The 3-day and 2-day decision times are CMS’s description of typical timing, not regulatory limits like those in Medicare Advantage.
• The estimate of about 6.4 million beneficiaries comes from the CRS report.
• The payment example is illustrative. The 10% share and the $20,000 procedure are not CMS figures.
• The service list reflects the first performance year. CMS notes that codes may change.
• The comparison table and the practical steps for practices reflect this analysis’s reading of CMS’s WISeR documents and the 2026 Medicare Advantage rules.

Sources

• CMS, WISeR (Wasteful and Inappropriate Service Reduction) Model
• CMS, WISeR model provider and supplier fact sheet
• CMS, WISeR model frequently asked questions
• CMS, Prior authorization and pre-claim review initiatives
• Congressional Research Service, In Focus IF13133 on the WISeR model, December 16, 2025 version
• Medical Group Management Association, Letter to House appropriators seeking WISeR reform, November 13, 2025

Frequently asked questions

Which states are in the WISeR model?

The model runs in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington. It applies to people with traditional Medicare in those states and does not apply to Medicare Advantage.

Do providers have to get prior authorization under WISeR?

No. For the listed services, providers can request prior authorization or skip it and have the claim reviewed before payment. If prior authorization is requested and not affirmed, Medicare will deny a claim for the service.

How are WISeR vendors paid?

Participants receive a share of the expenditures associated with care they avert, adjusted for performance, and face financial penalties for inappropriate denials.