Medicare is entering a new era of oversight. With the launch of the Wasteful and Inappropriate Service Reduction (WISeR) model on Jan. 1, 2026, CMS will shift from post-payment audits to technology-driven pre-service review and prior authorization — a move that mirrors commercial payer processes.
Initially focused on select services in six states (Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington), the WISeR model is poised to expand. And that means every provider participating in Medicare needs to act now.
What’s Changing Under WISeR?
Instead of paying claims and reviewing them after the fact, CMS will require pre-authorization for high-risk services, using AI and peer-review validation to reduce fraud, waste and abuse. Reimbursement will now hinge on documentation that is accurate, timely and aligned with Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs).
What Medical Practices Should Do Now
✅ Audit your front-end revenue cycle processes, including eligibility verification and prior authorization tracking
✅ Align documentation standards with CMS expectations and provide training across roles — from front desk to clinical teams
✅ Identify WISeR-impacted services and prepare documentation checklists
✅ Establish or update your corporate compliance plan to reflect WISeR requirements and OIG standards
✅ Explore technology solutions that streamline pre-service workflows
RCM: The Frontline of WISeR Compliance
Revenue cycle management will be critical. Delays in gathering documentation, routing authorization requests or managing denials could disrupt care and impact cash flow. Practices must align now or risk falling behind.
Why It Matters
Medicare accounted for over $1.12 trillion in healthcare spending in 2024. With estimates that up to 25% of healthcare costs are waste, WISeR represents not just a pilot — but the future of Medicare oversight. Preparing now is key to staying compliant, getting paid, and preserving patient care.
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