CMS announces new innovative WISeR Model
The Centers for Medicare & Medicaid Services (CMS) just announced a new Innovation Center model called the Wasteful and Inappropriate Service Reduction (WISeR) Model. This model’s goal is to help stop waste and protect beneficiaries with Medicare from getting services they don’t need by ensuring beneficiaries receive safe, effective, and necessary care. The program will use new technology, like artificial intelligence, to better control the use of certain medical services; however, licensed clinicians will still make the final decisions.
The WISeR Model will focus on select items and services that have been identified as particularly vulnerable to fraud, waste, and abuse, or inappropriate use such as skin and tissue grafts, nerve stimulator implants, and knee arthroscopy for knee osteoarthritis. This will not apply to emergency services, inpatient hospital care, nor services that would pose a substantial risk to patients if significantly delayed. Under this model, doctors and medical suppliers in the assigned regions can choose to send prior authorization requests ahead of time or have the claim medically reviewed post-service but before payment. Beneficiaries with Medicare Advantage won’t be affected, and everyone on traditional Medicare can still go to the provider of their choice.
CMS has issued a Request for Applications for companies interested in participating in the WISeR Model. Companies selected to participate in the model will operate in assigned geographic regions and must have clinicians with appropriate expertise to conduct medical reviews and validate coverage determinations. Per CMS, model participants will receive payments based on their ability to reduce unnecessary or non-covered services (inappropriate utilization) and lower spending in Traditional Medicare.
To view the Model Overview fact sheet, visit: https://www.cms.gov/files/document/wiser-fact-sheet.pdf.
For more information on the WISeR Model, visit: https://www.cms.gov/priorities/innovation/innovation-models/wiser.
The WISeR Model can be also seen on the Federal Register at: https://www.federalregister.gov/.
