Earlier this month, we laid out the details of the new CMMI Wasteful and Inappropriate Spending (WISeR) model. In this piece, we'll discuss the opportunity for health systems in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington to turn the compliance burden of this new requirement into an accelerant for operational efficiency.
Our mission at Vega Health is to be the objective, trusted partner equipping health systems everywhere to scale AI solutions that improve patient care and operational efficiency. It's how we approach every interaction with our customers – and WISeR is no different.
So first, we recognize the additional strain this new program puts on health systems in these states. WISeR represents a vastly different CMMI Model than any that has come before – where participation isn't optional, but required. It's a complex new workflow for any revenue cycle team, dealing with a CMS technology partner incentivized to deny or delay claims.
The administrative burden is real. The ambiguity around implementation is frustrating. And the financial incentives built into the program create legitimate concerns about inappropriate denials.
But the chaos of the program's rollout risks obscuring an opportunity. Health systems that respond to WISeR strategically can build capabilities that deliver value far beyond a narrowly scoped Medicare program.
The question isn't how you'll comply with WISeR. The question is whether you'll use this mandate as a catalyst to build prior authorization infrastructure that strengthens your revenue cycle operations with all payers, and positions you as a leader.
The Mistake of Responding Reactively
The natural response to WISeR is defensive: weather the ambiguity, minimize disruption, get through the compliance requirements, and advocate for CMS to ease the burden. Many health systems will:
• Assign WISeR compliance to existing RCM staff already stretched thin
• Use the technology partner portals (if and when they finally exist, and work) as submission channels
• Treat each prior authorization request as a one-off administrative task
• Limit the volume of the 14 procedures included in the initial WISeR program.
This approach keeps you compliant. But it leaves value on the table.
Consider a mid-sized health system in Texas. They have no guidance from their assigned technology partner, limited clarity on submission processes, and revenue cycle teams already managing prior authorization for Medicare Advantage and commercial payers. If they treat WISeR as just another compliance box to check, they'll bear additional administrative burden and miss a chance to gain leverage.
But if that same health system recognizes that CMS is signaling the future - more AI-enabled revenue cycle management - they can use this moment differently.
The Strategic Opportunity: Five Questions to Ask
Before you default to reactive compliance, your health system should consider these five questions:
1. Are we building capabilities, or just checking boxes?
WISeR forces you to document medical necessity more explicitly, organize clinical data systematically, and integrate additional prior authorization workflows into care delivery. While WISeR represents the immediate need, the correctly built capabilities can streamline prior authorization work with commercial and Medicare Advantage payers as well.
WISeR is inconvenient and hasn't been rolled out with health systems needs in mind. BUT, it can be the nudge to build the infrastructure you've been considering: standardizing and automating prior authorization across all payers.
2. Can this infrastructure work across all your payers, not just Medicare?
Medicare Advantage plans and commercial insurers already require extensive prior authorization. If you build infrastructure narrowly focused on CMS technology partners and WISeR procedures, you've created a compliance silo.
But if you build platform capabilities that handle prior authorization regardless of payer, you've created an asset. The workflows you build for WISeR can immediately extend to the prior authorization requests consuming your revenue cycle team's time across all payers.
That's the difference between building for compliance and building for capability.
3. Are you learning from denial patterns, or just responding to individual denials?
CMS technology partners will use AI to identify patterns in your documentation that trigger denials. If you're only responding to denials one request at a time, you're playing defense.
If you're using AI to analyze your own denial patterns: identifying which procedures, which documentation gaps, which clinicians need support – you're playing offense. You can address systemic issues before they become weaknesses that drive denials.
4. Can we turn the AI being used against us into an advantage?
CMS technology partners are paid to maximize savings by identifying documentation deficiencies and denying requests. Their AI learns from patterns across thousands of submissions to find reasons to say no.
You can deploy AI that learns from those same patterns to predict denials before submission, optimize documentation to match Medicare coverage criteria, and ensure requests are approved on first submission. Use AI to level the playing field for your system.
5. What happens when WISeR expands?
CMS has made clear that WISeR is a pilot model, not a final destination. If the program demonstrates that AI-enabled prior authorization reduces spending (and it will, given how the incentives are structured), expect expansion to more states and more procedures.
Health systems that build scalable infrastructure now won't need to scramble when expansion happens. They'll already have the workflows, the technology, and the institutional knowledge to absorb new requirements without operational disruption.
Finding the Right Partner to Build Your Strategic Response
A strategic response to WISeR has three components: immediate compliance capabilities, operational improvements that extend beyond Medicare, and long-term infrastructure that prepares you for the next wave of payment changes.
Immediate compliance (30 days):
• Implement technology that can support your revenue cycle management team to submit prior authorization requests to any WISeR technology partner or MAC
• Train RCM staff on AI-optimized documentation requirements
• Establish workflows that minimize delays to patient care while meeting prior authorization timelines
Operational improvements (90 days):
• Implement AI-driven analytics to identify denial patterns and documentation gaps
• Create feedback loops so clinicians learn what documentation CMS technology partners require
Long-term infrastructure (12 months):
• Build platform capabilities that adapt to changing prior authorization requirements without workflow disruption
• Leverage WISeR infrastructure to accelerate separate prior authorization work with commercial insurers and Medicare Advantage
• Use prior authorization data to inform value-based contracting negotiations
The difference between reactive and strategic isn't the initial investment. It's what you build that lasts beyond immediate compliance needs.
Short-Term Survival vs. Strategic Build: What's the Difference?
Short-Term Survival Approach:
• Use WISeR tech partner portals when available
• Assign to existing staff
• Focus on 14 WISeR procedures
• Reinvent the wheel when requirements change
Strategic Build Approach:
• Implement platform that works across all payers
• Build AI-optimized documentation workflows
• Apply learnings to MA and commercial prior auth
• Scale effortlessly when WISeR expands
The strategic approach delivers value that compounds over time rather than evaporating when the compliance requirement changes.
Why Vega Health Built for This Moment
At Vega Health, we've been building prior authorization infrastructure designed for exactly this scenario. Our approach differs from CMS technology partners in a fundamental way: we're not paid to maximize denials. Our incentives are aligned to help health systems provide the care patients and clinicians want.
We use AI to optimize submissions so they're approved on first attempt. Our platform integrates with your existing EHR systems, can help your staff with submissions to the technology partners or MAC in your state, and provides analytics that help you improve documentation systematically rather than responding to denials reactively.
And critically, our infrastructure doesn't just handle WISeR. It can be used for prior authorization programs from Medicare Advantage, commercial payers, and whatever comes next. When CMS expands WISeR, you won't need to build new capabilities. You'll already have them.
We work directly with RCM teams to implement quickly, adapt to your workflows, and align our success with yours: more approvals, faster turnaround, less administrative burden.
The Choice You're Making Right Now
Every health system in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington is making a choice, whether they realize it or not, about how they handle compliance. You can build narrowly: processes specific to WISeR technology partners, workflows that handle only the 14 covered procedures, systems that need to be rebuilt when requirements change.
Or you can build strategically: infrastructure that extends across payers, AI capabilities that improve your position, and institutional knowledge that turns you from a reactive compliance organization into a proactive revenue cycle leader.
The administrative burden of WISeR is real. The ambiguity is frustrating. The incentive structure is concerning.
But the opportunity to build something that lasts, and that serves your organization far beyond Medicare compliance, is also real.
For more information on how Vega Health can help your health system turn WISeR compliance into strategic advantage, contact us at info@vegahealth.com.
