CMS Rolls Out WISeR Model to Streamline Prior Authorization Process

Strategic Insights -

The Centers for Medicare & Medicaid Services (CMS) has announced the rollout of the WISeR model, a voluntary six-year pilot program aimed at leveraging technologies like artificial intelligence (AI) to ensure timely and appropriate Medicare payments for select items and services. This model, set to run from January 1, 2026 to December 31, 2031, includes technology companies with expertise in providing medical necessity recommendations using enhanced technology like AI and machine learning.

Key Takeaways:

  • The WISeR model will review original Medicare plans and exclude Medicare Advantage, inpatient-only services, emergency services, and services that pose a substantial risk to patients if delayed.
  • The model excludes a specific subset of items and services initially, including skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy for knee osteoarthritis.
  • Participants will be required to have clinicians validate technologically driven determinations, and the model will operate as a pre-treatment decision, unlike post-pay audits by unified program integrity contractors or recovery audit contractors.
  • The prior authorization process can be labor-intensive and challenging, with estimated administrative and financial costs of up to $25 billion per year.
  • Some have expressed concerns about the WISeR program's potential effects on provider operations and patient care, citing issues and lawsuits in the private sector related to similar technology models.
  • A U.S. Senate permanent subcommittee released a report detailing its investigation of Medicare Advantage plans' prior authorization process, revealing barriers to seniors' access to care and potential targeting of costly services for denials.
  • The WISeR program may incentivize denials if companies are compensated based on averted wasteful care, potentially increasing the risk of financial pressures overriding human oversight.
  • CMS has announced that certain "gold card" providers who achieve high affirmation rates may be exempt from the WISeR review process, reducing administrative burden.
  • Health care providers and industry groups can prepare by engaging with CMS, offering feedback, advocating for model updates, and pushing for standards for WISeR contractors that require transparency on algorithms, including training data, validation processes, and bias safeguards.

Statistics:

  • Estimated administrative and financial costs of prior authorization process: up to $25 billion per year
  • Duration of the WISeR model: six years (January 1, 2026 to December 31, 2031)
  • Percentage of denials overturned after appeal: over 90% in a reported lawsuit
  • Number of pages in the U.S. Senate permanent subcommittee's report: 54
  • Year of release for the report: 2024
  • Number of Medicare Advantage payors mentioned: at least one prominent payor with an implementation of a similar program plagued by lawsuits

Sources:

  • Birmingham Medical News
  • Mondaq Ltd
  • U.S. Senate permanent subcommittee report (October 17, 2024)
  • CMS announcement (no specific date mentioned)