On January 5th, health systems in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington State began submitting prior authorization requests under the new "Wasteful and Inappropriate Service Reduction" (WISeR) model from CMS. For the first time, these health systems were required to seek prior authorization under Original Medicare.
The revenue cycle teams that tried to submit requests over the last few days likely discovered this firsthand.
Health systems in six states right now will struggle to submit claims for 14 procedures. They're complying with a program that remains fundamentally ambiguous in critical areas, administered by technology companies with financial incentives to delay or deny care approvals, and implemented despite the concerns of every major healthcare association representing their interests.
Let's be clear about what's happening here, what these health systems are actually facing, and what they can do to level the playing field.
What WISeR Actually Requires
Select procedures, including epidural steroid injections, vertebral augmentation, and skin substitutes for chronic wounds, scheduled for January 15th and after now require prior authorization or pre-payment medical review in six states.
Prior Authorization vs. Pre-Payment Review
Prior Authorization: Submit request before delivering service. Get determination within 3 days. Proceed with advance clarity on payment.
Pre-Payment Review: Deliver service first, then submit claim. MAC suspends claim for review before payment, and the CMS technology partner will perform a post-procedure review. Creates payment uncertainty.
Under WISeR, providers choose which pathway to use.
CMS contracted six technology companies to process requests using AI: Cohere Health (Texas), Genzeon (New Jersey), Humata Health (Oklahoma), Innovaccer (Ohio), Virtix Health (Washington), and Zyter (Arizona). They promise three-day determinations.
What makes this unprecedented: Original Medicare operated on retrospective audits, not prospective prior authorization. WISeR changes that, coupling the change with a concerning compensation structure for its technology partners.
The CMS technology partners will be paid based, in part, on a percentage of the savings they generate. The more they deny or delay, the more they have the potential to earn. CMS has never structured a program this way before, and they're doing it as their first systematic foray into prior authorization for Original Medicare.
The Ambiguity Health Systems are Navigating Right Now
Major healthcare associations including the American Hospital Association requested that CMS delay implementation by at least six months in order for health systems to prepare. These groups pointed to insufficient engagement with CMS, unclear technical requirements, and concerns about the burden this would place on already-stretched clinical and administrative staff.
CMS did not delay. And here's where health systems are today:
Of the six technology partners, only three have published any publicly-available WISeR-specific information on their websites. Humata Health has a dedicated provider portal and held a webinar on January 7th. Genzeon created a WISeR page and held a provider information session on December 18th. Zyter published guidance directing providers to work with the local Medicare Administrative Contractor (MAC).
The other three? Nothing. Cohere Health, Innovaccer, and Virtix Health have published no WISeR-specific guidance, no portal information, no submission instructions. Texas health systems trying to comply with a federal mandate have no clear path from the technology partner that's supposed to process their requests.
What is a MAC?
Medicare Administrative Contractors (MACs) are private companies that contract with CMS to process Medicare claims for specific geographic regions. They handle day-to-day operations like claims processing, provider enrollment, and beneficiary services for Original Medicare.
Under WISeR, MACs serve as an alternative submission pathway: providers can submit prior authorization requests to their MAC, which will forward them to the assigned WISeR technology partner within one business day.
Even in states where guidance exists, critical questions remain unanswered: What exactly triggers AI auto-approval versus human clinical review? How do you appeal a denial when the timeline for delivering care is already compressed? What happens when the portal is down or the MAC doesn't forward your request within the promised timeframe?
This isn't just complex. Complexity means requirements are documented but difficult to meet. This is ambiguous. Health systems are required to comply with something that isn't fully defined, using systems that may not be ready, with consequences that could include claim denials and payment delays.
The Incentive Structure Problem
Beyond operational ambiguity, WISeR's incentives create a difficult challenge for health systems.
Prior authorization in Medicare Advantage plans has already demonstrated what happens when financial incentives aren't aligned with patient care. Senate investigations have documented how major insurers use predictive AI to increase denials for post-acute care. Class-action lawsuits allege that AI algorithms systematically deny necessary care to maximize profits.
Now, the companies reviewing WISeR prior authorization requests get paid more when they generate savings. They're not paid based on accuracy, appropriateness of care, or patient outcomes. They're paid based on how much they prevent Medicare from spending.
CMS – and the technology partners – have made assurances that:
Adjustments for performance metrics will prevent inappropriate denials;
Safeguards include human clinical review for any denial; and
Routine audits will ensure determinations align with Medicare coverage criteria.
But as RCM teams debate submitting prior authorization requests or proceeding directly to pre-payment review: the technology partner processing your request has a direct financial interest in saying no. And in many states, health systems don't even know how to submit that prior authorization request in the first place.
We'll explore the full scope of these misaligned incentives in an upcoming piece. For now, what matters is that health care leaders in these states are aware of the structure they're working within.
What You Can Do Now
What should health system leaders in these six states do now?
First, know your technology partner and your MAC. Understand which entity you're submitting to and what guidance they've published (if any). If you're in a state where no guidance exists, document that fact. When claims are delayed or denied, that documentation will matter.
Second, prepare for AI review differently than you would for human review. These algorithms will likely flag any gaps in documentation. If medical necessity isn't explicitly documented with specific language matching Medicare coverage criteria, expect a denial. The AI doesn't infer. It matches.
Third, recognize WISeR for what it is: a program that places yet another burden on health systems while introducing a new middleman with perverse incentives into payment decisions. You didn't create this situation. But you're the ones managing the consequences for your staff while trying to ensure patients get necessary care.
There's a Better Way to Respond
The WISeR compliance burden is real. But it doesn't have to derail your operations, revenue, or compromise patient care.
At Vega Health, we've built prior authorization solutions specifically for use cases like this to support health systems. We are already implementing a payer specific prior authorization solution for commercial insurance and are adapting our technology to help health systems navigate WISeR. We can implement and integrate quickly for health systems. We'll work directly with your RCM team to adapt our solutions to your workflows. And critically, our incentives align with yours: we succeed when you get approvals efficiently.
In our next pieces, we'll go deeper into the technical infrastructure requirements that WISeR exposes and the incentive structures CMS has created. We'll also discuss how forward-thinking health systems are using this moment not just for compliance, but to build AI capabilities that serve them far beyond WISeR.
But first, you need to get through this week. Document everything. Push for clarity from your technology partner and MAC. Protect your patients and your revenue cycle teams in a system that wasn't designed for them and wasn't quite ready for launch.
This is the reality of WISeR. You're not imagining, or responsible for, the chaos. And you're not alone navigating it.
*For more information on how Vega Health can help your health system navigate WISeR compliance with a solution built for rapid deployment and aligned incentives, contact us at vegahealth.com, or message us on LinkedIn.*
