WISeR: Protecting Medicare Beneficiaries and Taxpayers
Centers for Medicare & Medicaid Services
Transforming the Future of America's Health Care
The CMS Innovation Center's Wasteful and Inappropriate Service Reduction (WISeR) Model is one of CMS' key strategies for ensuring beneficiaries receive safe and medically appropriate care for their conditions.
Patient Safety First
WISeR prioritizes patient safety by targeting a narrow set of items and services that have been a source of fraud, waste, abuse and inappropriate utilization, which can present a very real threat of patient harm such as pain, bleeding, infection, anxiety, or other adverse effects.
Medicare Coverage Policy Stays the Same
WISeR does not change existing Medicare coverage policy or payment to providers and suppliers for covered services. WISeR supports the accuracy and efficiency of CMS’ review for compliance with existing Medicare coverage policy in statues, regulations, National Coverage Determinations, and Local Coverage Determinations. CMS will monitor and incentivize participants’ accurate determinations to ensure they adhere to coverage guidelines. Health care coverage for people with Medicare will not change, and they retain the freedom to seek care from their Original Medicare provider or supplier of choice.
Bringing Medicare Review into the 21st Century
By combining enhanced technology and experienced clinicians, WISeR brings Original Medicare's medical necessity review process into the 21st century. The model improves speed, accuracy and consistency of review while ensuring all non-affirmations (denials) require the review of a human clinician with appropriate clinical background.
Benefits for Providers and Beneficiaries
Health care providers who opt for prior authorization will know in advance that they will be paid for services they deliver, while beneficiaries will receive fast, accurate determination of whether certain services are reasonable and necessary, promoting safety and clinically appropriate, effective care.
Protecting Against Inappropriate Denials
WISeR's payment methodology disincentivizes inappropriate non-affirmations through audits, quality scores, and payment adjustments for inaccurate determinations. Providers, suppliers, and beneficiaries retain their rights to appeal any denied claims.
WISeR supports our shared commitment to improving the health and well-being of the American people, while also protecting federal tax dollars.
Aligning to Administration’s MA Reform
Secretary Kennedy’s pledge to fix prior authorization in Medicare Advantage is about finding the right balance for review: enough to protect patients but not so much that it interferes with their timely access to medically necessary care. WISeR models best practices in Original Medicare for how to conduct prior authorization by zeroing in on those services vulnerable to waste and abuse because of inadequate implementation of existing statutes, regulations, National Coverage Determinations, and Local Coverage Determinations. It aligns with the pledge’s goals of greater transparency and communication, real-time response to minimize delays in care, and medical professionals reviewing all clinical denials.
Learn more: visit the WISeR webpage and read new WISeR FAQs.
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PharmD, BCCCP; Co-founder LNK Pharmacy Solutions LLC
1dCenters for Medicare & Medicaid Services what about medication prior authorization processes? Currently there are a lot of instances of waste and abuse in this area secondary to non evidence based criteria used by PBMs to approve/deny medication coverage. There are no guardrails or standardization of specific med PA processes allowing PBMs to create med PA criteria that focus on increasing revenue through drug reimbursement rather than using evidence based medicine. Examples include providing non evidence based medication alternatives when excluding a medically necessary medication, innapropriate med PA criteria questions that cause delays in coverage, disregarding specific FDA diagnosis that have 2b or better drugdex micromedex support, changing formulary coverage whenever they want - leading to medication abandonment, and many many more examples. All of this leads to increased administrative costs for providers and delays to therapy for patients that lead to med adherence issues, increased hospitalizations and many other outcomes that lead to increased healthcare spend.
Initiatives like WISeR are a step in the right direction toward protecting patients while advancing smarter, more efficient care delivery.
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1wImportant step toward protecting both patients and taxpayers 👏
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1wCenters for Medicare & Medicaid Services, we really appreciate the work being done through the WISeR Model to make sure Medicare beneficiaries receive safe and appropriate care. It is great to see efforts that protect patients while also being mindful of costs for taxpayers.