Medicare picks participants for WISeR model, including radiologist-owned tech company

WISeR will focus on over a dozen services Medicare says are often subject to fraud, including image-guided decompression of the spine, epidural steroid injections for pain management, and percutaneous vertebral augmentation. Medicare previously said such services are often prone to abuse, and it’s offering incentives to tech firms curb their utilization. 

“Participants will earn shared savings by reducing unnecessary care and meeting performance targets,” ACR noted in its news update. “Providers and suppliers who do not submit prior authorization requests for included services claims will automatically be subject to medical review to confirm compliance with Medicare coverage, coding and payment criteria before payment.”

The American Hospital Association previously urged the Centers for Medicare and Medicaid Services to delay the model for at least six months to give providers more time to prepare. Meanwhile, the Society of Interventional Radiology recently announced its opposition, contending related care delays could potentially kill seniors. 

The model excludes several clinical scenarios such as inpatient stays, emergency care or instances when prior authorization may pose “substantial risk to patients if significantly delayed.” Technology companies tasked with handling these expedited reviews must utilize the expertise of clinicians in reaching their decisions, the agency emphasized. Final claim-denial denials will rest in the hands of docs and “not machines.”

CMS will test the model over six years beginning in 2026. The agency said it chose the six states because they have adequate volume to measure the model’s impact, geographic diversity, and currently provide coverage for skin and tissue substitutes, among other factors. 

Participants’ payments will be adjusted based on their performance against established measurements. This will include the ability to support “faster decision-making for providers and suppliers” while improving the prior authorization experience for both docs and their patients. Officials emphasized that WISeR will not change Medicare coverage nor payment criteria, with beneficiaries still free to seek care from their physician of choice. 

Members of Congress also have voiced their opposition to WISeR, echoing concerns presented by physician groups. Multiple democratic members of the U.S. House on Nov. 11 introduced legislation to block the model from happening. Those sponsoring the bill include Reps. Rick Larsen, D-Wash., Suzan DelBene, D-Wash., Kim Schrier, MD, D-Wash, Greg Landsman, D-Ohio, Ami Bera, D-Calif., and Mark Pocan, D-Wis. 

“As a doctor and former chief medical officer of Sacramento County, I’ve seen how harmful prior authorization can be when it delays or denies necessary care for patients,” Bera said in a statement Nov. 11. “The WISeR model takes that a step further by financially rewarding companies for denying care through so-called ‘averted expenditures.’ That creates a dangerous incentive to put profits ahead of patients’ health. These decisions should be made by doctors, not by algorithms designed to cut costs.”