Under Medicare’s WISeR model, providers in six states must operationalize a choice between prior authorization and post-service, pre-payment review for selected services.
CMS’s Wasteful and Inappropriate Service Reduction (WISeR) Model began January 1, 2026 and runs through December 31, 2031. It applies to selected services furnished to people with Original Medicare in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. It does not apply to Medicare Advantage. For affected services, providers and suppliers can submit a prior authorization request before care or proceed to a post-service, pre-payment review.
The operational choice happens before the service
The two paths lead to very different revenue-cycle risk. Prior authorization asks for a provisional coverage decision before the selected item or service is furnished. The alternative allows the service to proceed, but the claim is held for post-service, pre-payment review. That can move uncertainty into the period after clinical work has already occurred.
CMS says Medicare coverage, payment rules, and appeal rights do not change under the model. The new operational burden is deciding which review path to use, submitting the right clinical support, and preserving evidence of the decision through claim submission.
A front-desk checkbox is not enough
Operationally, this belongs in one controlled workflow shared by scheduling, clinical staff, authorization specialists, and billing. The team must first identify whether the beneficiary has Original Medicare, whether the service and location fall within WISeR, and whether prior authorization will be requested.
The record should capture the selected path, submission date, supporting documents, reference or tracking number, response, and any resubmission. The claim team should not have to reconstruct those facts after a pre-payment hold appears.
Technology does not remove clinical accountability
CMS describes WISeR as using enhanced technology, including artificial intelligence and machine learning, to support review. The agency also states that clinicians employed by model participants review non-affirmation decisions. Practices should therefore treat the response as a coverage workflow result, not as an automatic coding verdict.
A non-affirmation should trigger a structured review of the coverage criteria, order, medical-necessity narrative, required records, dates, and provider signatures. If the service is still planned, correct the documentation package before simply resubmitting the same material.
Build one control that follows the claim
Use a WISeR work queue tied to the appointment and claim. Assign an owner, due date, review path, decision status, and next action. Block claim release when the required evidence is missing, and monitor pre-payment holds separately from ordinary payer denials.
The practical rule is simple: make the review-path decision before the service, then carry the evidence through billing. That turns prior authorization from an isolated administrative task into a visible revenue-cycle control.
Practical takeaway
Confirm Original Medicare, state, and selected-service applicability before the visit.
Document whether the team chose prior authorization or post-service, pre-payment review.
Store the submission, clinical support, decision, tracking number, and resubmission history together.
Route non-affirmations back to coverage and documentation review before resubmission.
Do not apply WISeR rules to Medicare Advantage claims.