CMS introduces prior authorization model - WISeR

Earlier this summer, the Centers for Medicare and Medicaid Services (CMS) announced a new Center for Medicare and Medicaid Innovation (CMMI) model, which they claim will help reduce excess spending in the Medicare program. Called the Wasteful and Inappropriate Service Reduction (WISeR) Model, this voluntary initiative from CMS aims to reduce unnecessary healthcare spending and improve patient safety by leveraging Artificial Intelligence (AI) and Machine Learning (ML). WISeR will start on January 1, 2026, and will focus on streamlining prior authorization for select outpatient services that are vulnerable to fraud, waste, or abuse. Providers in selected states will have the option to submit prior authorization requests or undergo post-service/pre-payment reviews for the designated services. This represents a shift in how certain services are evaluated and reimbursed, with implications for documentation, service justification, and care planning. All reviews will be conducted by licensed clinicians using standardized, evidence-based criteria. WISeR does not change Medicare coverage or payment policies, and it excludes emergency and inpatient-only services, as well as Medicare Advantage plans.

However, it’s important to note that occupational therapy services are not currently included in the list of targeted services. Examples of included services are skin and tissue substitutes, electrical nerve stimulators, and knee arthroscopy for osteoarthritis, although CMS has indicated they may expand the list of targeted services over time. Although occupational therapy is not directly impacted at this time, practitioners should stay informed about the model’s implementation and potential future implications, including whether therapy services may be included at a later date. AOTA will continue to monitor the implementation and execution of the Model. Questions about WISeR should be directed to Regulatory@aota.org.