Pre-Authorization? Medicare's New WISeR Model

Let me start off with one assurance: if you are in a Medicare Supplement plan, you are still in the plan that provides the most access and least hassle. This is not a reason to change! It is simply something to be aware of and that you can be sure I’m watching.

One of the big reasons I always advocate for a combination of Medicare and a Medicare Supplement is that you aren’t required to get Prior Authorization for Services with your Medicare Supplement. However, on June 27, CMS announced The WISeR Model, which will be applied to Traditional Medicare (Parts A and B). WISeR stands for “Wasteful and Inappropriate Services Reduction.” This program will run for 6 years, until December 31, 3031, and affect Texas, Arizona, New Jersey, Ohio, Oklahoma, Washington.

The WISeR model will require Medicare beneficiaries (through their doctors) to obtain Prior Authorization for certain treatments. This includes 17 treatments that the CMS considers wasteful, of low value or effectiveness, may not align with actual health needs, and/or may lead to complications.

The first thing that gives me pause is the way the Prior Authorization review process will be handled. CMS states that a clinical reviewer (nurse, physician, or specialist with relevant expertise) will be the final say in approval of authorizations, but that AI will be used to help streamline the process.

I hope that this review process proves effective and doesn’t end up looking like the AI system that Insurance Companies currently use. Some insurance companies are facing legal actions and regulatory moves involving Medicare Advantage plans because of AI failures. On the flip side, AI can bring certain advantages to Prior Authorizations, such as making sure all documents are completed and attached, and expediting claims that meet all of the guidelines.

The second thing on my mind regarding the WISeR Model is that the list is flexible. Things that are currently on the list may be removed, and the list may be added to, as well. CMS reserves the right to add, remove, or substitute services during the WISeR model (2026–2031).

In summary, I know that Medicare suffers from fraud in outrageous amounts, and something must be done about it. I’m personally a fan of making the penalties/consequences of fraud harsher, but that is not the world that we live in today. The WISeR Model is one way to try reducing fraud and overutilization of procedures that have more affordable alternatives (and are sometimes bypassed).

The changes have not taken effect quite yet. CMS is taking bids from AI providers, and we will see who they chose. Certain legislators are also pushing back against this new model and trying to shut it down at the funding level. Perhaps an agreeable solution will be reached in the days ahead, most importantly, BEFORE all of the voting bodies leave for the holidays.

What I ask of you: If this passes, and if you have experiences with this in the future (either good or bad), let me know. Hearing from those who have “boots on the ground” is the best resource that I have, and it allows me to provide better insight to all of my clients.

Glad to be here,

Robert Ledman