MEDICARE LAUNCHES NEW PILOT PROGRAM IN ARIZONA

MICHAEL T. BRADEN JANUARY 16, 2026 MEDICARE NEWS

Picture of Braden MEdicare Insurances WISeR Poster, the new Pilot program of Medicare 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 new, voluntary pilot program currently operates in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. It is expected to run from January 1st, 2026, through December 31st, 2031.

It seems like a week goes by without hearing about some form of 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 created by CMS to review a limited set of medical services that have historically been 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.

WISeR DEFINED

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 THIS WISeR PILOT BE IMPLEMENTED?

The premise of this new program is to use advanced technology, including artificial intelligence (AI) and machine learning, hand-in-hand with physicians and other healthcare professionals to review a select group of medical services before the procedures can be approved and performed. I am sure your first thought is, "Why are they messing with my Medicare?" right? 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, before they are rendered. Honestly, the goal is not to deny care; rather, it is to make sure every Medicare beneficiary receives safe and appropriate treatment.

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

The WISeR program is 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 the vast majority of 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 GOING TO REVIEW EVERY THING MY DOCTOR TELLS ME?

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

These particular services were carefully selected based on medical research, Medicare coverage rules, and reports indicating misuse.

The goal of WISeR is to identify areas where previous fraud, waste, and abuse have been documented. Medicare does not want to lessen.

Emergency and hospital-only services are excluded from this program, along with services that would increase the patient’s risk if delayed.  

WHO CONDUCTS THE WISeR REVIEWS FOR CARE?

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

Medicare's goal is 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. The other 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 with certain Medicare processes and procedures.

IS EVERYONE AFFECTED BY THE NEW MEDICARE WISeR PILOT PROGRAM?

It is important to mention that 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 their benefits from Original Medicare in the six "test states" it is possible that some of your services subject to review, depending on whether your provider or state applies to participate in the pilot program.

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

No, it is important that we do not get concerned about your plan. Your plan will not change. period. The WISeR model does not change 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 DOES WISeR AFFECT THE CARE YOU 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 serve as an added 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 NEW MEDICARE WISeR PROJECT HOPES TO ACCOMPLISH

The Medicare WISeR Model represents an effort to increase transparency and protect both the patient 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 leverage 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.