12/16/2025

CMS WISeR (Wasteful and Inappropriate Service Reduction) Model

Effective Jan. 1, 2026

The Centers for Medicare & Medicaid Services (CMS) is launching a new program which aims to decrease wasteful spending and is scheduled to be implemented January 1, 2026.  This model will employ prior authorization:

•  Only for 15 services (one of which is skin substitute / CTP application to DFUs and VLUs)
•  Only for Medicare Part B beneficiaries
•  Only for services performed in certain sites of service
•  Only in 6 states

If all of those criteria are met, the provider has the option to submit a prior authorization request for the service.  If all of those criteria are met, and the provider chooses to not submit a prior authorization request for the service, CMS says that claim will be subjected to pre-payment review.

We are re-sharing the resources available (http://www.apma.org/WISER) on this issue.

Also note that APMA continues to advocate to Congress to stop the implementation of this program. For example, APMA  endorsed H.R. 5940, Seniors Deserve SMARTER (Streamlined Medical Approvals for Timely, Efficient Recovery) Care Act. Introduced by Representative Suzan DelBene (D-WA), this legislation would repeal the WISeR Model and prevent the expanded use of prior authorization in fee-for-service Medicare.

Please do not hesitate to contact APMA Advocacy staff if you have any questions.