WISeR’s Impact on Medicare: A Comprehensive Guide for Agents
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WISeR’s Impact on Medicare: A Comprehensive Guide for Agents
A big change for Medicare began on January 1, 2026 with the launch of the Wasteful and Inappropriate Service Reduction (WISeR) Model. Developed by the Centers for Medicare & Medicaid Services (CMS) Innovation Center, it’s designed to employ enhanced technologies along with human clinical review to ensure timely and appropriate Medicare payment for select items and services.
For brokers and agents who sell both Medicare Advantage and Medigap plans, understanding WISeR is essential in communicating how the model introduces utilization review into Original Medicare. It’s also crucial to explaining why the new model weakens the traditional “no prior authorization” Medigap talking point.
Inside the Model: Scope, States and Services
A six-year pilot created to test new approaches to care delivery and cost control, WISeR runs from January 1, 2026 through December 31, 2031. It operates in six states, including Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington, which collectively represent roughly one in five Medicare fee-for-service (FFS) beneficiaries.
Why is there a need for this type of model? According to the Medicare Payment Advisory Commission (MedPAC), Medicare spent up to $5.8 billion on low-value services in its claims-based analysis. Medicare Part B spending on skin substitutes, one of the model’s targeted service categories, rose substantially and exceeded $10 billion annually by the end of 2024. Those spending levels clearly are not sustainable for the Medicare program.
WISeR targets a specific set of service categories identified by CMS as either commonly overused or historically associated with higher rates of waste, fraud and abuse. These services apply to care delivered in hospital outpatient departments, ambulatory surgery centers and office and home settings within the pilot states. The list includes:
- Skin and tissue substitutes (including wound applications)
- Electrical nerve stimulators (multiple types)
- Epidural steroid injections for pain management
- Cervical fusion
- Arthroscopic knee procedures for osteoarthritis
- Percutaneous vertebral augmentation for vertebral compression fractures
- Hypoglossal nerve stimulation for obstructive sleep apnea
- Deep brain stimulation, sacral nerve stimulation and other implantable devices
Model Modifications
Some things change, and some stay the same. That’s the case with the WISeR Model.
It doesn’t alter Medicare coverage policy, nor does it alter payment rates, restrict a beneficiary’s right to choose any provider who accepts Medicare or introduce new coverage criteria. The model does, however, more consistently and proactively apply existing medical necessity standards. Standard Medicare appeals rights remain intact, including peer-to-peer review for physicians who want to make the case for a specific patient’s clinical situation.
What the WISeR Model also does is change when utilization review occurs. Previously, Medicare might audit claims after payment, retroactively catching waste and fraud. Under WISeR, for these 17 service categories, that review happens before payment, either through voluntary prior authorization or mandatory pre-payment medical review.
How the Process Works
Unlike traditional Medicare, which has relied on Medicare Administrative Contractors (MACs) for claims processing, WISeR introduces six technology-focused private companies that compete to serve as model participants. These WISeR model participants — Cohere, Genzeon, Humata, Innovaccer, Virtix and Zyter — deploy artificial intelligence (AI) and machine learning tools and combine them with licensed clinician review to assess prior authorization requests.
Providers and suppliers in pilot states have two options for WISeR-listed services:
- Submit a prior authorization request (proactively, before the service is performed) either directly to a model participant or through their MAC.
- Perform the service without prior authorization and subject the claim to prepayment medical review, a process that can delay payment and disrupt practice cash flow.
Although the WISeR Model is technically voluntary, claims that are not submitted for prior authorization will be automatically subject to the prepayment review process. Healthcare providers who want predictable reimbursement will find prior authorization to be the more practical path.
This technology-driven review process is designed to move quickly. Most prior authorization determinations are expected within 72 hours, but expedited review is available when standard timelines could jeopardize a patient’s health or safety. Healthcare providers with consistently high approval rates may eventually qualify for “gold card” status, which would exempt them from prior authorization requirements for covered services.
New Medigap Talking Points
Because Medigap plans are secondary payers, they follow Medicare’s lead instead of independently evaluating medical necessity. If Medicare approves a claim, Medigap pays its share of the cost.
Medigap plans can’t deny claims that Medicare has already approved. Unlike Medicare Advantage, there is no network or referral requirement, and therefore, no prior authorization.
Although it doesn’t eliminate that structural advantage, the WISeR Model introduces a new condition. If a service on the WISeR list is performed without prior authorization, Original Medicare may deny payment. If Medicare denies payment, Medigap won’t cover the cost either. The Medigap plan is bound by Medicare’s determination.
What exactly does this mean? For the included set of services, Medigap coverage is now conditional on the prior authorization process being completed. Even if it affects only a small number of services, it alters the absoluteness of a claim that previously was made without qualification.
The majority of Medicare services, such as routine physician visits, hospitalizations, lab work, imaging, preventive care and specialist consultations, are unaffected by WISeR. For most clients in most situations, the traditional Medigap value proposition stays the same.
Many of the services on the WISeR list are high-acuity procedures where guidance by healthcare providers will typically drive the process. A well-informed patient and agent or broker can help ensure the right questions get asked early.
The Role of AI and Why It Matters to Your Clients
One of the most distinctive aspects of WISeR is its heavy reliance on AI. Because the model participants are technology companies instead of traditional managed care organizations (MCOs), their business model is built around deploying AI and machine learning to assess prior authorization requests at scale.
According to the American Medical Association (AMA), the standard physician practice spends almost 15 hours (two business days) every week obtaining an average of 31 prior authorizations for its patients. In an AMA survey, 86% of physicians described prior authorization load as a “high” or “extremely high” burden, with 91% saying the process delays care and negatively affects clinical outcomes.
AI has genuine potential to improve speed and consistency. McKinsey & Company estimates that AI-enabled prior authorization processes could reduce manual effort by 50% to 75%, thereby boosting efficiency, reducing costs and freeing healthcare payers and providers to focus on complex cases and actual care delivery and coordination. Some researchers believe providers could save more than $355 million by solely utilizing electronic prior authorizations.
Under WISeR, the hybrid model is designed to use technology for initial reviews while requiring final decisions to be made by licensed clinicians. That safeguard matters, as AI-assisted denials in the Medicare Advantage space have come under scrutiny. Some in the healthcare industry have expressed concern that algorithms enhanced for efficiency may also be optimized for denial rates in ways that harm patients. To alleviate this potential risk, CMS has built in performance metrics, accuracy audits and appeal rights.
For your clients, the most reassuring message is that WISeR is applying the same coverage criteria that Medicare has always had. However, it’s doing it more consistently and proactively. The enforcement mechanism has changed, but the rules haven’t.
Short-Term WISeR Communication Challenges
Since WISeR first launched, hospitals and healthcare providers have reported difficulties adjusting to the model, including gaps in communication about the new rules and burdensome administrative requirements. Following are communication challenges agents and brokers should anticipate:
Clients Who Think Medigap “Covers Everything”
Many Medigap policyholders, especially long-time Plan G or Plan N enrollees, understand that their plan covers what Medicare approves, no questions asked. WISeR doesn’t change that fundamental structure, but it adds a step. If your client receives a denial related to a WISeR service and their Medigap plan won’t cover the cost, they will want an explanation.
Provider Confusion Becomes Beneficiary Confusion
Because healthcare providers are still adapting to WISeR workflows, some may fail to obtain prior authorization when required because the system is new and complex. If a provider proceeds without authorization and the claim is denied, your client may blame their Medigap plan, even though it performed exactly as designed.
Questions About AI and Trust
Some older Americans are skeptical of AI, especially for healthcare. Therefore, they might be wary about the effects of the WISeR Model. Your role is to explain that AI is reviewing documentation against the same rules that have always existed, not making arbitrary coverage decisions.
The Medicare Advantage Comparison Problem
For years, a clean differentiator between Medicare Advantage and Medigap has been the presence (or absence) of prior authorization. If prospects or clients mistake WISeR's narrow list of services for a broad prior authorization requirement like Medicare Advantage, you may lose sales or clients who don't understand.
Practical Messaging Adjustments for Brokers
The goal is to update your messaging in a way that is accurate and honest. Here are messaging adjustments you can incorporate:
Try: “With Medigap, there’s no prior authorization from the insurance plan itself. Medigap follows Medicare’s lead, so if Medicare approves a service, Medigap pays its share. Medicare recently introduced a new pilot program that requires advance approval for a specific list of specialty procedures in certain states, but that applies to a narrow set of services, and your doctor’s office will handle that process.”
Try: “Medigap is much simpler than Medicare Advantage in terms of prior authorization. Medicare Advantage plans require prior authorization for a wide range of everyday services. With Medigap, the only pre-approval requirement comes from Medicare itself for a narrow list of specialty procedures under a new CMS pilot program. That process is handled at the provider level, not by you.”
Try: “If your physician orders one of the procedures on CMS’s review list, he or she will need to obtain advance approval from Medicare before the service is performed. This is similar to how Medicare Advantage plans work for certain services. The approval is based on the same medical necessity criteria Medicare has always used, except now it’s being reviewed proactively instead of after the fact. If you’re planning a procedure, just make sure your healthcare provider knows to check whether advance approval is needed.”
Try: “I understand this is frustrating, and I want to make sure you understand your options. If your doctor believes this service is medically necessary, he or she has the right to request a peer-to-peer review with the Medicare reviewer. You also have standard Medicare appeal rights. Your Medigap plan itself hasn’t denied anything; we need to address Medicare’s determination first.”
Long-Term Rate Stabilization: From Fraud Reduction to Premium Stability
If the WISeR Model works as intended, it’s good news for Medigap. That’s because Medigap premium increases are primarily driven by the growth of Medicare’s total spending on FFS claims.
When Medicare pays for inappropriate, fraudulent or low-value services, that spending flows through the system and contributes to the actuarial trends that insurers use to set future premiums. Reducing that waste not only saves taxpayer dollars but potentially moderates the cost growth against which Medigap carriers must price.
WISeR services accounted for $12.3 billion of all Part B spending in traditional Medicare in 2024, up from $2.4 billion in 2019. CMS estimates that the changes through the new model will reduce Medicare spending on skin substitutes by roughly 90% in 2026.
The six-year structure of the pilot is aimed at giving CMS time to assess outcomes, refine the model and determine whether expansion to additional services and states is warranted. If WISeR performs as designed and reduces low-value care without inappropriately denying necessary services, it establishes a template for broader utilization management in traditional Medicare.
For brokers, this long-term dynamic is worth knowing and sharing when warranted. Clients who are nervous about any prior authorization in their Medigap product can be reassured that the WISeR Model is designed to protect the sustainability of the Medicare program. This, in turn, protects the value of their Medigap coverage.
A Note on Competitive Dynamics
The traditional prior authorization contrast between Medicare Advantage and Medigap is now less binary. Medicare Advantage plans require prior authorization for a broader and more varied set of services, and their denial rates have come under increasing congressional and regulatory scrutiny. WISeR’s 17 targeted services represent a narrow, evidence-based list, not the expansive utilization management apparatus of a managed care plan.
It’s important to explain to prospective clients that both products now involve some level of prior authorization, but the scale, scope and administrative burden are dramatically different. Medigap clients are dealing with a narrow list of specialty procedures. Medicare Advantage enrollees face prior authorization requirements for a wide range of services, including routine specialist care (in many plans).
Next Steps
WISeR is already in effect, so it’s essential to modify any sales materials or standard presentations that include unqualified "no prior authorization" language. Use the new model as an opportunity to demonstrate your proactive and knowledgeable guidance to clients. Other recommended steps include:
- Knowing your states. If you have clients in Arizona, New Jersey, Ohio, Oklahoma, Texas or Washington, WISeR is relevant to them. Also, monitor CMS communications for potential expansion of the model.
- Knowing the service list. Familiarize yourself with the 17 WISeR-covered services. Being aware of what’s on the list will help you answer client questions intelligently.
- Explaining provider responsibility to your clients. The best protective action a client can take is to ask their provider whether they need Medicare prior authorization before any specialty procedure.
- Using this as a differentiator. Clients who have been sold a Medigap plan by a broker who never mentioned WISeR only to encounter a problem are likely to feel misled. Brokers and agents who accurately and proactively explain the model build client trust.
The structural advantages of Medigap remain intact and substantial. Provider choice, comprehensive cost coverage, nationwide acceptance and predictable benefits don’t change under WISeR. But, no longer is the phrase “no prior authorization” as clear.
Frequently Asked Questions
According to CMS WISeR model resources, the following services require prior authorization or prepayment review under WISeR:
- Electrical Nerve Stimulators (NCD 160.7)
- Sacral Nerve Stimulation for Urinary Incontinence (NCD 230.18)
- Phrenic Nerve Stimulator (NCD 160.19)
- Deep Brain Stimulation for Essential Tremor and Parkinson's Disease (NCD 160.24)
- Vagus Nerve Stimulation (NCD 160.18)
- Induced Lesions of Nerve Tracts (NCD 160.1)
- Epidural Steroid Injections for Pain Management excluding facet joint injections (L39015, L33906, L39036, L39240, L39242, L36920, L38994, L39054)
- Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (L33569, L34106, L34228, L38201, L34976, L35130, L38737, L38213)
- Cervical Fusion (L39741, L39799, L39770, L39758, L39762, L39793, L39773, L39788)
- Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee (NCD 150.9)
- Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (L38276, L38307, L38398, L38387, L38310, L38312, L38385, L38528)
- Incontinence Control Devices (NCD 230.10)
- Diagnosis and Treatment of Impotence (NCD 230.4)
- Percutaneous Image-Guided Lumbar Decompression for Spinal Stenosis (NCD 150.13)
- Skin and Tissue Substitutes (L35041, L36690)
When does the WISeR Model come into effect?
The WISeR trial period began on January 1, 2026 and ends on December 31, 2031.
Where does the WISeR Model apply?
The WISeR Model applies to Medicare providers in six states:
- Arizona
- New Jersey
- Ohio
- Oklahoma
- Texas
- Washington
Does the WISeR Model affect Medicare Advantage plans?
No, the WISeR Model only applies to Original Medicare. It doesn’t change any plans or benefits, but introduces prior authorization requirements for some services.
Which companies are WISeR Model Participants?
The current list of WISeR Model Participants is:
- Cohere Health, Inc. (Texas)
- Genzeon Corporation (New Jersey)
- Humata Health, Inc. (Oklahoma)
- Innovaccer Inc. (Ohio)
- Virtix Health LLC (Washington)
- Zyter Inc. (Arizona)
Participants will be assessed based on processing volume, clarity, and timeliness, and receive a share of averted expenses instead of a fixed-fee.
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