CMS Releases FAQ Discussing New WISeR Model

As a follow-up to its recent announcement of the new Wasteful and Inappropriate Service Reduction (WISeR) Model (which we have previously covered here: CMS Unveils New Prior Authorization “WISeR Model” for Electrical Nerve Stimulators, Skin and Tissue Substitutes and Knee Arthroscopy), the Centers for Medicare and Medicaid Services (CMS) has published answers to some of the most frequently asked questions concerning the WISeR Model in a new FAQ page containing thirteen FAQs as of August 12, 2025.

In the FAQs, CMS goes into greater detail on the planned implementation of the WISeR Model as well as how the model fits into CMS’s overarching goals concerning patient safety, data privacy, and ensuring Medicare savings. Of note, the FAQs discuss participant compensation and the denial and appeals process. It also notes how the WISeR model specifically aligns with HHS Secretary Robert F. Kennedy Jr.’s and CMS Administrator Dr. Oz’s pledge to fix the prior authorization system. 

Participant Compensation

The model participants (i.e., the ones who will be using AI to make determinations on claims for services targeted by the WISeR Model) will be compensated solely on a percentage of savings generated from their reviews and the participants must have all potential denials reviewed by a human clinician, as the claim cannot be denied solely by AI technology. To guard against excessive denials, the participants will be audited by CMS to verify that their determinations are in line with Medicare coverage criteria. The participants will be given quality scores based, in part, on the audit results, which may result in financial penalties for inaccurate determinations and those participants with a high rate of inaccuracy may be terminated from the model altogether.

Prior Authorization Non-Affirmation

For prior authorization requests which were denied or “non-affirmed,” the provider/supplier may resubmit the request an unlimited number of times, which the participant will bear the cost of processing. If the request is denied, providers/suppliers may still render the service and submit a claim to the MAC for repayment. The MAC may then choose to approve or deny the claim, where denial of the claim by the MAC will constitute an initial payment determination, which would be subject to the existing administrative appeals processes available to providers, suppliers and people with Medicare.

As noted previously in our coverage, the WISeR model is scheduled to launch its six-year term on January 1, 2026, in six selected states (Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington).

WISeR Model Frequently Asked Questions