WiSeR, Faster, Fairer? A Look at CMS’s New Model for Reducing Low-Value Care
Post Written by Sarah Dunbar, Consultant
CMS’s new WiSeR model brings third-party tech vendors into the Medicare FFS world, using artificial intelligence and machine learning to manage prior authorization for certain services. The question is: can this actually reduce low-value care without sidelining provider-led accountability?
A New Kind of Model with a Familiar Goal
Ever since the leadership shift at CMMI, many have wondered when the next wave of payment model innovation would arrive. In June, CMS gave us a first glimpse: the WiSeR model, short for Wasteful and Inappropriate Service Reduction.
It is the first model announced under this administration, and it signals a meaningful change in direction. Instead of placing health systems or ACOs at the center, WiSeR makes third-party technology vendors the lead actors. The goal is to reduce unnecessary spending in Original Medicare (more commonly known as Medicare Fee For Service or M-FFS) by putting more guardrails around how certain services get approved.
The model begins in January 2026 and runs for six years, divided into two three-year performance periods. It will launch in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington.
Not Your Typical CMMI Participant
Unlike most CMMI models, this one is not about shared savings or managing the total cost of care. The core participants are tech vendors, many with experience in Medicare Advantage and Medicare FFS, who will use artificial intelligence, machine learning, and clinical review to determine whether targeted services meet Medicare’s medical necessity criteria.
These vendors will be paid based on the savings generated when unnecessary services are denied. Their compensation also depends on how timely and accurate their decisions are, how often denials are overturned, and how well they communicate with providers.
To encourage balance, CMS plans to include gold carding for high-performing providers and options for peer-to-peer review. These design elements suggest that CMS is seeking to modernize prior authorization without repeating the pain points providers have experienced elsewhere.
This is not a broad application of utilization review. Instead, CMS is targeting a small group of high-cost, high-volume services that it believes are vulnerable to overuse or fraud, including:
Skin and tissue substitutes
Implantable nerve stimulators
Knee arthroscopy
Diagnosis and treatment of impotence
Incontinence control devices
Stimulator services
Epidural steroid injections for pain
The list may evolve over time, but for now, the scope remains focused and applies only to Medicare FFS, not Medicare Advantage.
What Should We Be Watching?
While WiSeR is not technically a shared savings model, it may still have ripple effects for ACOs and other organizations participating in shared savings CMMI programs.
Shared savings dilution and overlap
If your ACO has historically high utilization in one of the WiSeR-targeted services, and those start getting denied under this model, that cost reduction may not show up in your shared savings calculations. In other words, the work your team may have done to manage utilization or reduce unnecessary services could get erased or attributed elsewhere.
CMMI has said WiSeR won’t change billing rules or adjust payment policies. But let’s be honest, in practice, it’s still unclear how vendor savings payments will be reconciled across programs. And if history is any guide, that clarity might not come until mid-model.
Workflow disruption
The model is designed to make prior authorization more efficient and consistent. But in the short term, the introduction of a new process limited to specific services and vendors could create new administrative tasks. Providers will likely need to learn new platforms, help patients navigate delays, and manage these additional demands with limited resources.
What Happens Next?
WiSeR attempts to strike a careful balance: reducing low-value care, bringing innovation to utilization review, and minimizing provider burden. There is meaningful potential here. The use of technology to support smarter decision-making could improve both consistency and accountability in prior authorization.
Still, key questions remain:
Will savings be credited to the right entities?
Will patients experience care delays for services that are medically necessary?
Can new oversight processes improve care quality without adding confusion?
WiSeR could represent an important step toward more modern and transparent utilization management. Or it could follow the path of past pilots that never reached scale. What is clear is that providers, ACOs, and states should pay close attention to this model, particularly in reviewing their service mix and potential overlap with WiSeR’s focus areas.
If value-based care is going to keep progressing, we need models that reward thoughtful, evidence-based oversight. WiSeR has the potential to move us in that direction, but only if its implementation supports the organizations already leading this work.
If you are participating in a CMMI model or preparing to join one, now is the right time to evaluate how WiSeR may affect your benchmarks and workflows.
At HSG, we help ACOs and provider organizations assess model alignment, manage risk exposure, and prepare for new layers of oversight. Let’s talk.
About the Author: Sarah Dunbar is a Consultant at Helgerson Solutions Group. Connect with her on LinkedIn.