In the Centers for Medicare & Medicaid Services’ (CMS’s) ongoing attempts to conquer fraud, waste, and abuse, it launched the WISeR (Wasteful and Inappropriate Service Reduction) Model as of the start of this year, using technology-enabled prior authorization for a set of items/services CMS believes are vulnerable to such issues. It’s currently limited to six states: Texas, Arizona, Washington, New Jersey, Ohio, and Oklahoma. Implementation details/operational steps are spelled out in CMS model materials. This matters for providers because it changes front-end billing workflows (documentation, ordering, timing, and appeals posture) for impacted services and sites of care.
The WISeR model reportedly is meant to combat fraud, and will employ private companies to test if artificial intelligence (AI) can handle the prior authorization process used to determine if a recipient of Medicare is eligible for funding for a health service. The model specifically will look at services CMS considers to be “particularly vulnerable to fraud, waste, and abuse.”
If you operate in WISeR states, treat it like a new “mini-utilization management” layer for Medicare; build a same-day documentation/PA (physician assistant) packet process, and track denial reasons from day one.
What services are included in the new initial phase of the WISeR program? My list here is not comprehensive:
These alone hit neurology, neurosurgery, urology, and pain management heavily.
These are some of the most targeted pain interventions nationwide:
These services are heavily utilized and frequently audited by Unified Program Integrity Contractors (UPICs), Recovery Audit Monitors (RACs), and Medicare Administrative Contractors (MACs) already.
Major spine and orthopedic procedures now subject to WISeR prior authorization include:
This is significant because these are high-value, high-volume services with significant reimbursement exposure.
Specifically targeted are:
This is a rapidly growing implant procedure with aggressive utilization growth.
These include:
These involve implantable devices and surgical interventions.
This is one of the most heavily targeted areas, and one you frequently litigate:
These products have been the subject of massive UPIC and U.S. Department of Justice (DOJ) enforcement actions already.
So, why did CMS choose these services, and why should providers be concerned?
CMS selected services that are:
CMS explicitly stated that the model targets services that are “known source(s) of potential waste … vulnerable to fraud, waste, and abuse … (and) costly, elective services.”
Critical legal implication most providers miss includes the following:
If providers do NOT submit prior authorization:
This effectively creates de facto mandatory prior authorization, even though CMS calls it “voluntary.”
CMS also confirmed it will expand services over time.
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The Centers for Medicare & Medicaid Services (CMS) operates a surveillance platform called the Fraud Prevention System (FPS) that analyzes Medicare claims across the full
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