Key Takeaways
What you will learn in this article
- 1WISeR (Wasteful and Inappropriate Service Reduction) adds AI-assisted prior authorization to traditional Medicare for a defined list of services in six states, for six performance years: January 2026 through December 2031.
- 2Providers choose between submitting a prior authorization request or accepting pre-payment medical review of the claim — skipping both isn’t an option for included services.
- 3Technology vendors review requests using AI, and they are paid a share of the spending their reviews avert. CMS says every recommendation to deny is made by a licensed clinician.
- 4Early data is reported, not official: in Texas about 62% of requests were approved initially, rising to 84% after physician review. FOIA records show 5,944 denials by two vendors in the first three months.
- 5In May 2026 the GAO ruled WISeR is a “rule” under the Administrative Procedure Act, opening the door to a Congressional Review Act repeal vote. Plan as if it stays.
- 6Practices outside the six states should still pay attention: WISeR is a test, and successful CMS Innovation Center models tend to expand.
Prior authorization has always been the defining difference between Medicare Advantage and traditional Medicare. Medicare Advantage plans use it heavily; traditional Medicare largely didn’t. That changed on January 15, 2026, when the CMS Innovation Center’s WISeR Model went live and began routing requests for selected services through AI-assisted review by private technology companies — the first time traditional Medicare has used the approach at this scale.
If you practice in one of the six model states and perform any of the affected services, WISeR is already part of your revenue cycle. If you don’t, it is still the clearest signal yet of where Medicare is heading on automation, denials, and documentation. This guide sticks to what CMS has published and what independent reporting has confirmed, and is clear about what is still unknown.
What WISeR Is, in Plain Terms
6
States
AZ, NJ, OH, OK, TX, WA
2026–31
Model years
Six performance years
13 of 15
Services active
Two delayed in April 2026
6
Tech vendors
One per state
WISeR targets a defined list of Part B items and services that CMS considers vulnerable to unnecessary use. CMS’s published examples include skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy for knee osteoarthritis. Fifteen services were originally selected; in April 2026, CMS delayed two of them — deep brain stimulation and percutaneous image-guided lumbar decompression — to allow more operational readiness, leaving thirteen active. Inpatient-only services, emergency services, and services where a delay would pose substantial risk to the patient are excluded.
| State | Technology participant | Medicare Administrative Contractor |
|---|---|---|
| Arizona | Zyter | Noridian (JF) |
| New Jersey | Genzeon | Novitas (JL) |
| Ohio | Innovaccer | CGS (J15) |
| Oklahoma | Humata Health | Novitas (JH) |
| Texas | Cohere Health | Novitas (JH) |
| Washington | Virtix Health | Noridian (JF) |
Model participants by state, per CMS. Medicare Advantage enrollees are not affected.
How the Two Paths Work
For an included service, the provider picks one of two routes. Both end with the same question — is the service reasonable and necessary under Medicare’s coverage rules? — but they put the financial risk in very different places.
Path A
Pre-payment medical review
- No prior authorization request is submitted
- The service is performed, then the claim is held for medical review before payment
- If the review finds the service not reasonable and necessary, the provider bears the risk of non-payment
- Supporting records must be produced after the fact, under the review’s deadlines
Path B
Prior authorization request
- Request submitted to the model participant directly or through the MAC
- Reviewed with AI/ML tools; any recommendation to deny is made by a licensed clinician
- A decision before the service, so the financial risk is known in advance
- CMS says providers with a strong compliance record may be exempted from review in future
For most practices Path B is the safer default: the documentation work has to be done either way, and a pre-service decision is better than discovering a denial after the procedure has been performed and paid for.
Who Reviews — and How They’re Paid
Each state’s technology participant uses AI and machine-learning tools to review requests and supporting documentation. CMS says all recommendations for non-payment are determined by appropriately licensed clinicians, and participants must employ clinicians to validate determinations. Participants are paid a percentage of the expenditures associated with the inappropriate care their reviews avert, adjusted by performance on process measures that include provider experience. Critics argue that paying vendors a share of averted spending rewards denials; CMS’s answer is the clinician sign-off and the performance adjustment. Both points are worth keeping in mind when you read a denial.
What the First Year Shows So Far
Seven months into the model, CMS had not published official denial, appeal, or overturn rates. What exists comes from reporting and records requests. Treat it as early and partial — but not as nothing.
Chart
Texas WISeR prior authorization approval rates (early reporting)
| Approved on initial review | ≈62% |
|---|---|
| Approved after physician review of initial non-authorizations | ≈84% |
| For context: typical Medicare Advantage approval rate | 90%+ |
Source: The Washington Post, as cited by Georgetown University’s Center on Health Insurance Reforms (June 2026). Limited period, one state; may not represent overall model performance. MA rates vary by service and plan.
WISeR so far
June 2025
Model announced
CMS announces WISeR for six states, starting January 2026.
December 2025
Pushback begins
H.R. 6361, the “Ban AI Denials in Medicare Act”, is introduced; four senators ask GAO whether the model is a rule.
January 15, 2026
Go-live
Technical issues push the effective date back from January 1. Providers report portal and communication problems.
Q1 2026
5,944 denials in three months
Records obtained by the Electronic Frontier Foundation show two vendors denied 5,944 requests; one vendor denied more than it approved and was put on a corrective action plan. One request went 83 days without an answer.
April 2026
Two services delayed
Deep brain stimulation and percutaneous image-guided lumbar decompression are pushed to a later performance year.
May 2026
GAO: WISeR is a rule
GAO’s May 12 determination opens a Congressional Review Act window; disapproval resolutions are introduced May 20.
Fall 2026Now
Funding fight
A House amendment to defund the model heads into year-end spending negotiations.
A Playbook for Practices in the Six States
Map your exposure
Pull 12 months of Medicare claims and flag every procedure on the WISeR list. Note volume, revenue, ordering providers, and which locations perform them.
Default to prior authorization
Make Path B the standard for every included service, with a named owner. Pre-payment review should be a deliberate exception, not what happens when nobody submitted a request.
Build documentation to the coverage policy
For each service, check the applicable NCD/LCD criteria and build a pre-submission checklist: conservative treatment tried and failed, imaging, functional scores, duration. AI review is pattern matching — give it the patterns.
Track every request like a claim
Log submission date, channel, reference number, decision, and decision date. Escalate anything outstanding past the expected turnaround — and keep the log, because it is your evidence if delays become a policy issue.
Appeal non-affirmations
Ask for physician-to-physician review where available, and appeal claim denials through the normal Medicare appeals process. In Texas, approvals rose from about 62% to 84% once physicians reviewed initial non-authorizations — persistence is paying off.
Watch for exemption
CMS says providers with demonstrated compliance may be exempted from review in future years. A clean approval record now is an asset later.
Outside the Six States? Here’s Why It Still Matters
Innovation Center models are tests, and the successful ones expand. WISeR is testing whether AI-assisted review can cut spending in traditional Medicare — exactly what Medicare Advantage plans and commercial payers have been doing for years, and alongside federal rules like CMS-0057-F that are pushing prior authorization onto electronic APIs. Whatever happens to WISeR itself, the documentation discipline it demands — clear evidence of medical necessity, captured at the point of care — is where every payer is heading. The same automation is also showing up after the claim is paid, in AI-driven E/M downcoding.
Free tool · No signupDays in A/R CalculatorPrior authorization delays show up as slower cash. See how many days of charges you have waiting to be paid.Check my A/RDoes WISeR affect Medicare Advantage patients?+
No. WISeR applies only to traditional (fee-for-service) Medicare in the six model states. Medicare Advantage plans run their own prior authorization programs.
Which states are in the WISeR Model?+
Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington, for performance years January 1, 2026 through December 31, 2031.
Does WISeR change Medicare payment rates?+
No. CMS says payment rates for included services don’t change. WISeR adds a review step; it doesn’t reprice the service.
Are AI systems making the final denial decision?+
CMS says all recommendations for non-payment are determined by appropriately licensed clinicians. AI and machine learning are used in the review process, but a clinician makes any denial recommendation.
What happens if I perform an included service without prior authorization?+
The claim goes to pre-payment medical review. If the service isn’t found reasonable and necessary, you bear the risk of non-payment.
Could WISeR be repealed?+
Possibly. GAO determined in May 2026 that the model is a rule, which makes it eligible for a Congressional Review Act disapproval resolution, and there are also legislative and funding efforts against it. Until something passes, practices should plan as if it stays.
Sources & References
- [1]CMS Innovation Center — WISeR (Wasteful and Inappropriate Service Reduction) Model
- [2]Congressional Research Service — Overview of the Medicare WISeR Model (IF13133)
- [3]Georgetown CHIR — CMS’s WISeR Model Faces Potential Repeal Following GAO Determination (June 2026)
- [4]Becker’s Hospital Review — WISeR’s high-stakes first year, in 8 questions
- [5]Medicare Rights Center — New records show WISeR causing inappropriate denials (September 2026)
- [6]DLA Piper — CMS launches WISeR Model: what providers need to know (January 2026)
