Have you heard about the latest innovation from CMS?
Beginning in 2026, the Centers for Medicare & Medicaid Services will pilot a new approach called the WISeR Model — short for Wasteful and Inappropriate Services Reduction. The focus? Reducing unnecessary and potentially harmful care in the Medicare Fee-for-Service (FFS) program through the use of technology-driven prior authorization.
Here’s the scoop: Select high-volume, high-cost services with a history of questionable value will now require prior approval in six pilot states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington. This change won’t affect all services, just a targeted list that includes procedures like nerve stimulators, spinal injections, and certain orthopedic interventions.
CMS plans to work with third-party entities—many already active in the Medicare Advantage world—to apply advanced technologies like artificial intelligence to speed up the decision-making process. The idea is to identify problematic claims earlier, reduce delays in care, and help providers ensure compliance before services are rendered.
Participation in the prior authorization process is optional, but providers who don’t submit in advance may have their claims flagged for pre-payment review. CMS has also floated a possible “gold card” policy down the road for providers with strong compliance records.
This won’t change what’s covered by Medicare, but it will change how—and when—coverage is confirmed for selected services.
Want to learn more? Details are available on the CMS WISeR model page.
BCAREV.com helps providers and healthcare teams stay informed and audit-ready when it comes to documentation, coding, and compliance. Let’s schedule a conversation to see what we can do for you.