Understanding the Medicare WISeR Program: A New Approach to Healthcare

Picture of Braden Medicare Insurance's WISeR Poster, the new Medicare pilot program aimed at reducing Waste, Fraud, and Abuse in Medicare.

If you have Medicare or plan to sign up soon, you may have heard about a new program called WISeR. This voluntary pilot program currently operates in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. It is expected to run from January 1, 2026, through December 31, 2031.

It seems like a week goes by without hearing about waste, fraud, or abuse in America, particularly in government programs. Well, to the government's credit, CMS (Centers for Medicare and Medicaid Services) is launching WISeR.

• The Medicare WISeR Model is a quality assurance program CMS created to review a limited set of medical services historically prone to misuse.

• The voluntary program is being tested in six states (New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington) through 2031.

• Medicare Advantage plan enrollees are not affected.

  
  

WHAT IS WISeR?

WISeR:

W - Wasteful

I - Inappropriate

S - Service

R - Reduction

WISeR is a pilot program created by the Centers for Medicare & Medicaid Services, or CMS. It acts as a quality check to ensure treatments are necessary and appropriate while also reducing fraud and waste.

Picture of Braden Medicare Insurance's Waste and Inappropriate Service Reduction Model.

HOW WILL THE WISeR PILOT BE IMPLEMENTED?

This new program uses advanced technology, including artificial intelligence (AI) and machine learning, alongside physicians and other healthcare professionals. This collaboration will review a select group of medical services before approving and performing procedures.

I know what you might be thinking: "Why are they messing with my Medicare?" Well, the simple truth is that the goal of the WISeR program is to identify, root out, and eliminate waste, fraud, and abuse in certain services identified beforehand. The goal is not to deny care; rather, it is to ensure every Medicare beneficiary receives safe and appropriate treatment.

WHY IS MEDICARE (CMS)STARTING THE WISeR PROGRAM NOW?

The WISeR program is designed for beneficiaries who have chosen Original/Traditional Medicare Fee-for-Service and a primary healthcare provider. Currently, healthcare providers are paid based on the volume of services they provide. While most doctors and healthcare providers have your best interests at heart, this payment structure can sometimes create situations that lead to misuse or fraud.

Misuse usually takes the form of prescribing unnecessary tests, suggesting unnecessary treatments, or recommending unnecessary procedures. This is fraud and abuse by a healthcare professional, potentially padding their wallets by receiving payments for unnecessary care.

Records provided to CMS by the Medicare Payment Advisory Commission show that Medicare spent nearly $6 billion in 2022 alone on services considered to have little or no clinical benefit.

Now that Medicare has the option and support for enhanced technology, WISeR is focused on speeding up the review process while also identifying cases where certain recommended or suggested treatments may not be the best or correct course of action based on the beneficiary's current health status.

IS MEDICARE ALWAYS GOING TO REVIEW EVERYTHING YOUR HEALTHCARE PROVIDER TELLS YOU?

The WISeR Model focuses on a small group of services Medicare has previously identified as having a history of waste, fraud, or abuse. Some examples include electrical nerve stimulator implants that are not FDA-approved, skin and tissue substitutes, and unnecessary arthroscopic procedures involving the knee when the issue is simply osteoarthritis.

WISeR selected these services based on medical research, Medicare coverage rules, and reports of misuse. WISeR aims to identify areas where previous fraud, waste, and abuse have been documented.

This program excludes emergency and hospital-only services, as well as services that would increase the patient’s risk if delayed.

WHO CONDUCTS THE WISeR REVIEWS?

The WISeR pilot focuses on a select group of services. If you’re recommended for one of these services, technology will help determine whether it meets Medicare’s coverage requirements. A licensed, expert clinician makes approval determinations for recommended procedures using established, evidence-based medical standards.

Medicare aims to streamline this process to make it faster and easier than your normal prior authorization process. CMS has set a goal to complete all Prior Authorizations within 72 hours. Another benefit of this new model is that it will greatly reduce paperwork for providers and ensure that Medicare beneficiaries receive appropriate care.

Drawing of the new CMS Pilot program RiseR, showing a Physician entering data into his computer. RISeR is designed to use Doctors and Advanced Technology to identify and eradicate Fraud, waste, and abuse in certain Medicare processes and procedures.

WILL EVERY MEDICARE BENEFICIARY BE AFFECTED BY THE NEW WISeR PILOT PROGRAM?

The WISeR plan will not change any aspect of your Medicare Advantage plan. You will continue to receive coverage and any required prior authorizations through your Medicare Advantage Insurance carrier just as you normally would.

For beneficiaries who receive benefits from Original Medicare in the six test states, some services may be subject to review, depending on whether your provider or state participates in the pilot program.

IF I LIVE IN THESE STATES WILL MY COVERAGE OR MY MEDICARE PLAN CHANGE?

No, your plan will not change. The WISeR model does not alter your current Medicare coverage. You can still visit any doctor or supplier that accepts Original Medicare. The amount Medicare pays for covered services also stays the same.

HOW WILL WISeR AFFECT THE CARE I RECEIVE?

After January 15, 2026, if your doctor recommends one of the listed services, there may be an additional step to confirm medical necessity. While you and your doctor still make the decisions, CMS aims for WISeR to add an extra layer of protection against potential fraud. This step ensures that medical decisions are supported by evidence and comply with Medicare’s coverage policies.

WHAT THE MEDICARE WISeR PILOT HOPES TO ACCOMPLISH

The Medicare WISeR Model aims to increase transparency and protect both patients and taxpayer dollars. By reducing wasteful spending on unhelpful or sometimes even harmful services, Medicare can focus its resources on care that makes a difference in people’s lives.

WRAPPING THINGS UP

The goal of the Medicare WISeR Model is to add a review step for certain high-risk services to confirm they’re medically appropriate for your specific situation. WISeR will use advanced technology, in collaboration with licensed medical practitioners, to improve processes and reduce the risk of waste, fraud, and abuse.

There will be no disruption or changes to your current Medicare Health plan, regardless of whether you live in one of these pilot states or not. Your premiums and benefits will not be affected by the WISeR program.

As we navigate these changes together, remember that the ultimate aim is to ensure you receive the best possible care. If you have questions or concerns, don’t hesitate to reach out for help!