The Centers for Medicare & Medicaid Services (CMS) has developed the Wasteful and Inappropriate Services Reduction (WISeR) Model effective January 1, 2026, through December 31, 2031. This model may impact many healthcare practices, especially those involved with wound care and grafting services.
WISeR was designed to reduce Medicare expenditures by combating fraud, waste, and abuse in Original Medicare. It will target services that are considered of low clinical value, medically unnecessary, or vulnerable to fraud and abuse. CMS estimates that a substantial portion of Medicare spending (over $5 billion annually) may be tied to such services. Other goals include:
The model will launch in six initial states: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. However, it is expected that the model will quickly be introduced to many other states since CMS is authorized by statute to initiate and expand demonstration projects at its discretion. We also expect CMS to expand the list of services subject to WISeR’s prior authorization requirements.
WISeR will introduce technology-enabled prior authorization processes for select services. It leverages enhanced technologies, including AI and machine learning to identify patterns of potentially wasteful services. The intent is greater accuracy with claims and better program integrity. Licensed clinicians will make final decisions on whether a request meets Medicare coverage requirements.
Furthermore, technology vendors will be responsible for implementing and streamlining the prior authorization process using their advanced technological solutions.
The model targets services identified as vulnerable to fraud, waste, abuse, or inappropriate use due to their potential for little to no clinical benefit. The list of services includes, but is not limited to:
Wound grafts, particularly skin and tissue substitutes, are explicitly included in the WISeR Model’s targeted services. Providers in the participating states should prepare for the new prior authorization process and ensure documentation supports medical necessity and clinical appropriateness. Participants in other regions should remain attentive to their development and outcomes as program expansion is likely.
The development of the WISeR Model represents a significant shift in Medicare’s approach to utilization management, emphasizing technology-driven prior authorization and external vendor partnerships to curb wasteful spending and enhance program integrity, potentially featuring such services as wound care and grafting.
Whether your state will be one of the first to use the WISeR Model or not, your practice is advised to consider changes to your protocol for these and other affected services so you can remain compliant with federal and state government requirements. Contact Chapman Law Group for a consultation and for answers to questions about how these changes may affect your practice.
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