WISeR Model (Wasteful and Inappropriate Services Reduction)

Current understanding

The WISeR Model is a CMS Medicare pilot that requires prior authorization by third-party contractors—using AI/enhanced technology review and paid on a savings-based contingency—for selected services in six states. A Senate CRA joint resolution to nullify the rule was rejected 46–50, leaving the model in effect. The model represents a significant expansion of utilization management into fee-for-service Medicare and has drawn scrutiny over AI-driven denials and contractor incentives.

Evidence log

• 2026-07-15 — Improving Seniors’ Timely Access to Care Act of 2025: cross-connection with improving-seniors-timely-access-to-care-act-2025: Both address prior authorization in Medicare — this bill sets electronic PA and transparency standards for Medicare Advantage, while the WISeR Model applies AI-assisted PA to fee-for-service Medicare, complementary policy tracks on utilization management. (novelty: 2)
• 2026-05-19 — Providing for congressional disapproval under chapter 8 of title 5, United States Code, of the rule submitted by the Centers for Medicare & Medicaid Services of the Department of Health and Human Services relating to “Medicare Program; Implementation of Prior Authorization for Select Services for the Wasteful and Inappropriate Services Reduction (WISeR) Model”.: 2026 — Senate rejected 46–50 a CRA joint resolution to nullify the CMS WISeR Model rule, so the six-state pilot using third-party contractors and AI/enhanced technology for prior authorization on selected Medicare services (paid on shared savings) remains in effect. (novelty: 3)
• 2026-07-16 — A joint resolution providing for congressional disapproval under chapter 8 of title 5, United States Code, of the rule submitted by the Centers for Medicare & Medicaid Services of the Department of Health and Human Services relating to “Medicare Program; Implementation of Prior Authorization for Select Services for the Wasteful and Inappropriate Services Reduction (WISeR) Model”.: cross-connection with prior-authorization-reform: WISeR expands prior authorization into fee-for-service Medicare via third-party AI review, running counter to broader legislative efforts to constrain prior authorization burdens. (novelty: 3)

Open questions

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