Your Questions Answered: How WISeR Protects Medicare Beneficiaries and Taxpayers

The CMS Innovation Center has added new FAQs to clarify the scope and purpose of the WISeR (Wasteful and Inappropriate Service Reduction) Model, including how it fulfills one of CMS' key strategies: ensuring people with Original Medicare receive safe and medically appropriate care for their conditions.

Some highlights:

Patient Safety First

WISeR does not change existing Medicare coverage policy or payment to providers and suppliers for covered services. WISeR supports the accuracy and efficiency of CMS’ review for compliance with existing Medicare coverage policy in statues, regulations, National Coverage Determinations, and Local Coverage Determinations. CMS will monitor and incentivize participants’ accurate determinations to ensure they adhere to coverage guidelines.

Health care coverage for people with Medicare will not change, and they retain the freedom to seek care from their Original Medicare provider or supplier of choice.

Bringing Medicare Review into the 21st Century

By combining enhanced technology and experienced clinicians, WISeR brings Original Medicare's medical necessity review process into the 21st century. The model improves speed, accuracy and consistency of review while ensuring all non-affirmations (denials) require the review of a human clinician with appropriate clinical background.

Benefits for Providers and Beneficiaries

WISeR's payment methodology disincentivizes inappropriate non-affirmations through audits, quality scores, and payment adjustments for inaccurate determinations. Providers, suppliers, and beneficiaries retain their rights to appeal any denied claims.

WISeR supports our shared commitment to improving the health and well-being of the American people, while also protecting federal tax dollars.

Aligning to Administration's MA Reform

Secretary Kennedy’s pledge to fix prior authorization in Medicare Advantage is about finding the right balance for review: enough to protect patients but not so much that it interferes with their timely access to medically necessary care.

WISeR models best practices in Original Medicare for how to conduct prior authorization by zeroing in on those services vulnerable to waste and abuse because of inadequate implementation of existing statutes, regulations, National Coverage Determinations, and Local Coverage Determinations. It aligns with the pledge’s goals of greater transparency and communication, real-time response to minimize delays in care, and medical professionals reviewing all clinical denials.

Learn more: read new WISeR FAQs and visit the WISeR webpage.

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