Coming January 2026: CMS Launches AI Program to Screen Prior Authorization Requests for Treatments
New CMS program, WISeR, will leverage third parties to screen prior authorization requests using technologically enhanced processes.
On July 1, 2025, the Centers for Medicare & Medicaid Services ("CMS") introduced the Wasteful and Inappropriate Services Reduction ("WISeR") program requiring prior authorization for select fee-for-service ("FFS") offerings to Medicare enrollees in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. The services targeted by WISeR include treatments commonly scrutinized (and often rejected) by payors such as nerve stimulators, cervical fusions, and incontinence treatments.
Under WISeR, CMS will partner with payors, including certain participating Medicare Advantage ("MA") plans, as "model participants" to test technology-assisted (AI) prior authorization review. Medicare-enrolled providers may submit requests for prior authorization to either the MA plan model participant or a traditional Medicare Administrative Contractor ("MAC") for approval. Upon submission, the model participant will utilize AI and other tools to review and approve (or reject) the requested treatments—including to determine if the requested treatment is "medically unnecessary." If a listed treatment is performed without prior authorization, the claim will be subject to prepayment "medical review," which combines "technology and clinician review."
Model participants will be "compensated based on a share of averted expenditures," integrating a financial incentive to scrutinize requests for prior authorization regarding the select services and perhaps increasing denials for such services. Similar contingency fee incentive structures have led to adverse results for providers in Medicare audits, and several states prohibit such arrangements when commercial plans are making payment determinations.
Further, CMS's expansion of the use of AI for medical necessity decisions may be in tension with certain state laws limiting the use of AI in utilization management (e.g., California's AB 72) and the Federation of State Medical Board's concerns with the use of AI by physicians. Medicare-enrolled providers in the relevant jurisdictions should anticipate the possibility for increased denials given the utilization of AI tools in Medicare FFS prior authorization as to the specified services both pre- and post-treatment.
As a best practice, providers should take measures to quickly operationalize prior authorization requests for the impacted services prior to 2026 and consider any necessary modifications to bolster provider documentation regarding implicated services. While the selected services are currently limited to non-inpatient services, providers should also anticipate CMS may soon expand WISeR's prior authorization requirements to inpatient services.
