When the Algorithm Says No: What Medicare's WISeR Model Means for Your Practice's Cash Flow

On January 1, 2026, the Centers for Medicare & Medicaid Services launched the Wasteful and Inappropriate Service Reduction model (WISeR), bringing technology-assisted prior authorization and pre-payment review to selected Original Medicare services in New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington. Requests began on January 5 for services delivered on or after January 15.

Now the Government Accountability Office has weighed in with a determination that opens the model to congressional review, and with it the real possibility of repeal. Suddenly a program built to run through 2031 has an expiration date nobody can predict.

Here's the part most coverage is missing. Whether WISeR survives the year or not, the operational lesson it has already taught is permanent, and every independent practice in the country should be taking notes.

What actually changed on January 1

Original Medicare has historically been the one payer that didn't make you ask permission first. You documented, you billed, you got paid, and any fight over medical necessity happened on the back end. That asymmetry is precisely why so many practices treated Medicare denials as a rounding error and built their denial-management muscle around commercial and Medicare Advantage plans instead.

WISeR inverted that. Under the model, selected services in the six participating states require a prior authorization request submitted through a model participant's electronic portal. The participants use machine-assisted review to triage those requests, with licensed clinicians making every final non-payment recommendation. CMS has said it will audit participants for inappropriate denials and hold them to an accuracy metric on their determinations.

CMS says enhanced technology can support the review, but trained clinicians must verify that selected services meet Medicare coverage criteria. The model also allows peer-to-peer review during resubmission before a final determination.

That makes the operational issue clear: a practice needs a complete submission, a visible status trail and a defined route for clinical review. The technology doesn't remove the need to prove medical necessity against the applicable Medicare criteria.

The submission still depends on complete documentation

This is the sentence we would put on the wall of every practice we work with: coverage criteria may be clinical, but the reviewer can act only on the documentation that reaches the request.

The American Hospital Association made this exact point in its comments to CMS on the model. The submission platforms in play do not use FHIR transactions, which means they do not pull from the EHR. Staff have to manually collect and extract clinical information and re-key it into a portal, and then do it a completely different way for commercial patients than for Original Medicare patients. Two workflows, two sets of habits, two chances to leave out the one note that would have gotten a first-pass yes.

Multiply that by a practice running thin on front-office staff, and incomplete requests become predictable rather than exceptional.

The financial consequence can be delay: additional time in scheduling and accounts receivable while a request is supplemented and reviewed. For a practice with a tight cash position, that's an operating issue rather than a paperwork issue.

Why the repeal question does not let you off the hook

It would be easy to read the GAO news and conclude that this is a temporary irritation for four states, two states, or none. That would be a mistake, for three reasons.

• First, the direction of travel is toward more structured review. CMS's CY 2026 Physician Fee Schedule changed skin-substitute payment after Part B spending rose from $252 million in 2019 to more than $10 billion in 2024. The final rule set a single 2026 payment rate of approximately $127.28 while CMS develops a more differentiated approach for later years.
• Second, Medicare Advantage isn't going anywhere. Whatever happens to WISeR in Original Medicare, MA plans have run prior authorization at scale for years, and MA penetration keeps climbing. The documentation discipline WISeR demands is the documentation discipline MA already demanded. Practices that build it now are building it for the payer mix they will actually have.
• Third, and this is the one that costs practices money quietly, a policy change doesn't resolve work already delayed. Open requests, resubmissions and related claims still need a named owner and a current status.

What we would do about it

At VOSKPO LLC, we don't treat prior authorization as a form-filling function. We treat it as the front edge of the revenue cycle, because that's what it has become. Here's the operating posture we would put in place, and it costs nothing to start this week.

• Build the packet before the request, not after the non-affirmation. For every service line subject to prior authorization, define in advance exactly which clinical elements the payer needs to see, and make assembling that packet part of scheduling, not part of billing. Fixing missing documentation is a workflow change, not a technology purchase.
• Standardize across payers instead of maintaining parallel workflows. The AHA's complaint about running one process for commercial and another for Original Medicare is real, and the answer isn't to wait for the portals to converge. Build one internal standard that satisfies the strictest payer you deal with, and use it everywhere. You'll over-document for some payers. That's cheaper than under-documenting for one.
• Use the review path. Track non-affirmations, resubmissions and peer-to-peer reviews as named work with an owner. A first response should never disappear into a general billing queue while the available review window closes.
• Age your prior-auth-related A/R separately. Blend it into the general bucket and it disappears. Break it out and you can see, in dollars, what the process is costing you. That's the only number that will ever get the workflow fixed.
• Watch the policy, but don't wait on it. If WISeR is repealed, you'll have built a denial-prevention discipline you needed anyway. If it survives and expands beyond six states, you'll already be running it. There's no version of the next three years where tighter documentation hurts you.

The uncomfortable summary

This is the work VOSKPO is designed to support for independent practices: clearer documentation, earlier exception handling and accountable follow-up. Any effect on denials or days in A/R must be measured from the practice's verified baseline and will depend on payer mix and execution.

This isn't an argument about artificial intelligence in healthcare. It's an argument about whether a practice can submit complete work, follow the request and use the clinical-review path before the service or payment is delayed.

The GAO determination may end WISeR. It won't end the scrutiny. Build for the scrutiny.

Ready to investigate where first-pass denials are coming from? VOSKPO offers a Free Revenue Review for independent practices using the available denial and A/R data to identify patterns and the next questions to test. Start at voskpo.com.