The operational guide is meant to help provider and suppliers understand the details for prior authorization submissions and determinations in states that will test the Wasteful and Inappropriate Service Reduction (WISeR) Model under Original Medicare.
The Centers for Medicare & Medicaid Services (CMS) said the 61-page guide offers an overview of the prior authorization submission and determination processes for Medicare-enrolled providers and suppliers that provide services included in the WISeR model that is being tested in New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington.
RELATED: New CMS model will test prior authorization in Original Medicare
The new WISeR model will launch January 1, 2026, to test how enhanced technology, like artificial intelligence, may streamline prior authorization within Original Medicare for services such as skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy for knee osteoarthritis.
The goal of the model, which originated from the Center for Medicare and Medicaid Innovation (CMMI) is to use analytics and AI to flag potentially low-value or unnecessary services in Original Medicare, explained Elizabeth Fowler, Ph.D., deputy administrator and director of CMMI, in a post for Health Affairs Forefront.
The model will focus on fewer than 125 Part B billing codes that account for $3 billion in spending, she wrote. It will examine a handful of procedures, such as arthroscopic knee surgery for osteoarthritis, that evidence indicates may be overused.
RELATED: Lawmakers take another stab at MA prior authorization reform
Although some industry experts were surprised that CMS would take on prior authorization in Original Medicare given the challenges and concerns of the process in Medicare Advantage, Fowler said it isn’t the first time that prior authorization-like tactics have been applied in the program. For example, Medicare follows a nationwide prior approval process for certain high-cost durable medical equipment.
Fowler said she understands concerns that the new model’s use of prior authorization may restrict access to needed services and potentially add to administrative burdens. That’s why it will be important to monitor patient access and ask questions while the model is rolled out. The answers to the questions will determine whether the model offers a successful approach for addressing low-value care.
“Skepticism about Medicare experiments is warranted,” she wrote, “but avoiding experimentation altogether would mean accepting the status quo—a crucial program straining under rising costs and uneven quality. For now, the most reasonable stance is watchful waiting: acknowledging the real problems WISeR seeks to address, recognizing the equally real risks it introduces, and insisting on transparency and accountability as it proceeds.”