I have been in revenue cycle management for over 18 years. And honestly it’s the first time Medicare has considered AI to review prior authorization, claims, and coding. But how they are doing it? Through WISeR which stands for Wasteful and Inappropriate Service Reduction. It was launched on January 1, 2026. It is not a policy update but basically a structural shift.
What is the Contribution of AI Inside WISeR?
CMS has partnered with six technology vendors and assigned them to six pilot states. This is the WISeR model. These companies use AI and machine learning to analyze prior authorization requests and flag claims for review.
What happens is that AI assesses whether prior authorization requests meet Medicare’s coverage criteria or not. Then a decision is issued.
AI Cannot Deny a Claim!
Yes, it can’t. A licensed clinician with proper expertise is required to review and confirm any determination not met in the claim. This is critical as this is a prerequisite before it goes to the provider and needs a human to make the decision.
Abe Sutton, the CMMI Deputy Administrator, was on an AMA and CMMI webinar in October 2025 where she said and I summarize, “contractors not to be incentivized deny claims, they are to do what’s right”.
Problems CMS Solves With WISeR
CMS cited in their research that the healthcare waste was up to 25% of the total US Healthcare spending, a big number, right? Well there’s more. The MPAC estimated that $5.8 billion in Medicare spending in the year of 2022 was solely toward services that had minimal clinical benefit.
All this because Original Medicare pays on the basis of the volume of services delivered and CMS acknowledges this right of the bat. Now with WISeR, it will create incentives for treatments and diagnostic tests that are not medically necessary.
WISeR Model Breakdown
It will be in effect for six years across six states: Oklahoma, Texas, Arizona, New Jersey, Ohio, and Washington.
The technology vendors running the model are:
- Virtix Health in Washington
- Zyter in Arizona
- Innovaccer in Ohio
- Humata Health in Oklahoma
- Cohere Health in Texas
- Genzeon in New Jersey
Know that these are not payers, they are AI-enabled review companies and being compensated based on the percentage they save on the waste. Also, there are some adjustments that are tied to the quality of the support providers experience throughout.
What Services Does This Model Cover?
CMS has described a list of services but NOT LIMITED to which include:
- Skin and tissue substitutes
- Electrical nerve stimulator implants
- Knee arthroscopy for knee osteoarthritis
- Epidural steroid injections for pain management
- Percutaneous vertebral augmentation for vertebral compression fractures
- Percutaneous image-guided lumbar decompression for spinal stenosis
Be aware that “not limited” language is 100% delibrate. CMS can add more services to the list over the course of six years and it won’t even need new rulemaking.
The Gold Card Exemption
There’s an exemption in all this, a Gold Card CMMI planning to pilot mid-2026. To get this card, providers need to build up a consistent record with affirmed authorizations and clean claims on the targeted services. This will give a complete exemption from WISeR review. So, providers, this exemption is something worth planning for.
The Bigger Picture
CMS has been very open to the fact that WISeR could be expanding to additional Part B services and more states if the pilots show promising results. This is because the Medicare Part B services as of now, don’t require any prior auth at all and the shift in Original Medicare with WISeR could become a broader shift across it.
I know this, and the billing and compliance teams at MedCare MSO are already working with providers in the pilot states. We are aligning prior authorization workflows and documentation practices with what WISeR actually requires.
