Ready to get wiser? According to a June 27th release by the Centers for Medicare & Medicaid Services (CMS), they are rolling out a “new Innovation Center model aimed at helping ensure people with Original Medicare receive safe, effective, and necessary care. Wasteful and Inappropriate Service Reduction (WISeR).” While this is a voluntary program for the first six years, the underlying concept seems transparent – testing the implantation of a prior authorization model for Original Medicare.
In addition to nearly limitless access to care sans a network, one of the notable features of selecting Original Medicare, coupled with a Medicare Supplement Plan, has historically been the lack of prior authorization and some of the red tape consumers can face with Medicare Advantage Plans. So, what is the short-term and long-term intent behind this voluntary model program? While we live in a reactionary world, I am not so sure this should cause significant alarm; however, it should capture our focus and attention. Anytime the government is testing something there is good reason – they intend to make a change… eventually.
The thesis of release is summarized in the following excerpt:
“CMS is committed to crushing fraud, waste, and abuse, and the WISeR Model will help root out waste in Original Medicare,” said CMS Administrator Dr. Mehmet Oz. “Combining the speed of technology and the experienced clinicians, this new model helps bring Medicare into the 21st century by testing a streamlined prior authorization process, while protecting Medicare beneficiaries from being given unnecessary and often costly procedures.”
A careful read of the release and related documents reveals key works such as reducing “low-value serves,” “minimal benefit,” “no clinical benefit,” “increase patient costs,” and “inflating heath care spending.” In other words, let’s harness the power of technology to limit unnecessary and/or potential harmful procedures to reduce costs for the patient, carrier, and Medicare Program. The release clearly indicates a narrow initial focus to include services “particularly vulnerable to fraud, waste, and abuse, or inappropriate use” such as “skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy for knee osteoarthritis.”
What then does this mean for Medicare recipients, for the 2026 plan year and beyond?
- If your Medicare Supplement carrier volunteers and is selected as a model participant, you may experience the WISeR Model in action – depending on your demographical region.
- Like most initiatives, guidance is emergent so it is hard to tell what the actual process will look like or how denials/redirections might work – especially in year 1 of the Model Program.
- There is an incentive for participants in that they “will be rewarded based on the effectiveness of their technology solutions for reducing spending on medically unnecessary or non-covered services. For each selected service, participants will receive a percentage of the reduction in savings that can be attributed to their reduction of wasteful or inappropriate care.”
- It is important to at least become familiar with this new program and your potential to experience some of the changes it will generate in 2026.
- It is critical not to blow things out of proportion as the year 1 model is extremely limited in scope and patently excludes “inpatient-only services, emergency services, and services that would pose a substantial risk to patients if delayed.”
Stay tuned for more updates and information in the weeks and months ahead!
For additional details, check out the following CMS information page: https://www.cms.gov/priorities/innovation/innovation-models/wiser