In 2026, Medicare Gets WISeR About Dealing with Waste, Fraud and Abuse
By Mitchell Lange
Beginning in 2026, the Centers for Medicare & Medicaid Services (CMS) will pilot the Wasteful and Inappropriate Service Reduction (WISeR) program. The trial program is intended to reduce wasteful spending in traditional Medicare by introducing new prior authorization requirements and utilizing new technologies like artificial intelligence (AI) and machine learning to expedite the review process.[1] Medicare providers in the pilot program states must be prepared to implement the new requirements, while other providers should be aware of the changing landscape and new processes introduced by CMS.
Background
The WISeR pilot program targets six states and a limited number Medicare services. Beginning in January 2026 and running through December 2031, the six states participating in the pilot program are: Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington.
CMS will implement the WISeR program with the assistance of private contractors who will utilize new technology to streamline claims. While the list of services is limited, the new prior authorization requirements will apply to all Medicare-enrolled providers in each of the six states.
WISeR Pilot Program Contractors
To run the WISeR pilot program, CMS has engaged six contractors that have experience implementing technology-enhanced prior authorization models, including Cohere Health Inc. (TX), Genzeon Corporation (NJ), Humata Health, Inc. (OK), Innovaccer Inc. (OH), Virtix Health LLC (WA), and Zyter Inc. (AZ). The contractors will utilize available technology, including AI and machine learning, to streamline the prior authorization process. Pursuant to the trial program, these companies will receive a portion of the averted costs attributed to their reviews and reductions in any waste, fraud or abuse.
Targeted Services
The WISeR trial program intends to reduce wasteful spending by targeting a pre-determined list of services that “may have little to no clinical benefit for certain patients and that historically have had a higher risk of waste, fraud, and abuse.”[2] The program will require the same information and clinical documentation that’s typically required for traditional Medicare, but this will be imposed earlier in the process. The initial services subject to prior authorization under the trial program include:
- Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds and Wound Application of Cellular and/or Tissue Based Products, Lower Extremities (only applies to selected WISeR MAC jurisdictions and states that have an active skin substitute LCD in place)
- Percutaneous Image-Guided Lumbar Decompression for Spinal Stenosis
- Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee
- Induced Lesions of Nerve Tracts
- Vagus Nerve Stimulation
- Phrenic Nerve Stimulators
- Electrical Nerve Stimulators
- Incontinence Control Devices
- Sacral Nerve Stimulators for Urinary Incontinence
- Diagnosis and Treatment of Impotence
- Percutaneous Vertebral Augmentation for Vertebral Compression Fracture
- Epidural Steroid Injections for Pain Management
- Cervical Fusion
- Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea
- Deep Brain Stimulation (implementation delayed because it is currently categorized as an inpatient service only and will not occur on Jan. 1, 2026)
Processing Requests Under the WISeR Program
Providers must follow new processes under the WISeR program for submitting claims. Under the pilot program, CMS specifies three scenarios in which a provider may receive approval for a claim:
- The provider submits a prior authorization request to a WISeR program contractor who then determines whether to affirm the request.
- The provider submits a prior authorization request to a participating Medicare Administrative Contractor (MAC), who then routes the request to a pilot program contractor.
- The provider submits a claim without prior authorization, which is then flagged by a MAC for pre-payment medical review by the pilot program contractor. During pre-payment review, the claim is automatically suspended until the pilot program contractor receives complete documentation to make a determination.
Notably, any denial of a claim must be reviewed by a human clinician and cannot be solely based on a determination by AI processes or technology. Providers may also appeal a decision using the existing Medicare appeals procedures.
Considerations
Historically, traditional Medicare has not had any prior authorization process. Transitioning to prospective requirements via prior authorization, instead of retrospective auditing could cause additional delays in receiving treatment as well as increase the administrative burden on providers. Moreover, the fact that the new contractors will receive a portion of the averted costs of the savings identified by the WISeR program creates a risk that the contractors may have a financial motive to aggressively deny necessary care to beneficiaries.
CMS, however, insists that it will work to avoid any adverse impact on beneficiaries or providers through adjustments to payments under the trial program based on different performance metrics including accuracy and timeliness of determinations. Routine audits by CMS will also ensure that determinations made by contractors are consistent with traditional Medicare criteria. Additionally, a provider may request an expedited review if a delay in receiving care due to the prior authorization requirement would jeopardize the health of the patient.
Key Takeaways
Providers need to be aware of the changing Medicare landscape for processing claims under traditional Medicare. The WISeR trial program is an attempt by CMS to reduce waste in Medicare services, and, in the future, CMS could roll out similar requirements throughout all 50 states. Providers in pilot program states must implement new processes and update workflows to ensure compliance with the new requirements. Providers in non-pilot program states should continue to monitor the rollout of the WISeR model and its impact on traditional Medicare services as future implementation could be inevitable if the program is successful.
------------
[1] Implementation of Prior Authorization for Select Services for the Wasteful and Inappropriate Services Reduction (WISeR) Model, 90 Fed. Reg. 28749 (July 1, 2025).
[2] WISeR (Wasteful and Inappropriate Service Reduction) Model, CMS.gov: Centers for Medicare & Medicare Services (Nov. 21, 2025), https://www.cms.gov/priorities/innovation/innovation-models/wiser.
