Is AI WISeR? CMS Models AI-based Prior Authorization Process in Six States

The Centers for Medicare and Medicaid Services (CMS) is poised to launch a bold, new initiative to reduce waste, fraud and abuse. Starting January 1, 2026, the Wasteful and Inappropriate Service Reduction (WISeR) Model will launch in six states—Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington, and run for six years. The program will employ enhanced technologies, such as artificial intelligence (AI) and machine learning (ML) to introduce prior authorization to select services within Medicare.

WISeR will target traditional fee-for-service Medicare services in those states that are especially vulnerable to waste, fraud and abuse. These services include skin and tissue substitutes, electrical nerve stimulators and knee arthroscopy for knee osteoarthritis. The model excludes inpatient-only services, emergency services and services that would pose a substantial risk to patients if delayed. However, CMS has indicated that it may expand the program to include additional services in future years.[1]

Starting January 1, AI and ML technology will dictate the prior authorization process to determine whether Medicare will pay for the claim before treatment is provided. If the claim is denied, a human clinician will review the claim before it is finalized. Providers within the six participating states may opt to submit a prior authorization request and be subject to AI and ML review or go through a post-service/pre-payment review and bear the risk of nonpayment.

The WISeR program has received significant resistance from the health care industry, reflecting longstanding and deeply rooted concerns about prior authorization requirements.[2] Medical professionals have consistently criticized prior authorization for impeding patient access to care. A 2024 survey by the American Medical Association cited 93% of physicians reported that prior authorization delayed access to necessary care for their patients.[3]

The American Hospital Association (AHA) urged CMS to delay the program’s launch by six months.[4] AHA raised concerns about several aspects of the model, including the lack of an appeals process for patients to challenge prior authorization denials, which is currently available under Medicare Advantage. Further, AHA highlighted that technology vendors will be paid if they help reduce Medicare spending, potentially incentivizing them to deny care.

Although there was a government shutdown, CMS has made no indication that it intends to delay the program from its January 1 launch.

If you have questions about how the WISeR program could impact your organization, please contact your Dinsmore health care attorney.