CMS WISeR Model: What Radiology Providers Need to Know

ACR® recently joined a webinar hosted by the AMA featuring the CMS Innovation Center (CMMI) about the upcoming Wasteful and Inappropriate Service Reduction (WISeR) Model, a six-year voluntary initiative. 

Effective Jan. 1, CMS will implement the WISeR Model in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington. This initiative targets select services under Medicare Part A and Part B that are vulnerable to fraud, waste and abuse.

CMMI confirmed the WISeR Model will launch Jan. 1 and will not be delayed due to the federal government shutdown. Some of the services selected directly impact the College’s interventional radiology members.

Abe Sutton, Director of CMMI, confirmed the model does not change physician payments for services selected for prior authorization under the model; providers can decide not to submit prior authorization requests and claims will be subject to pre-payment medical review. 

CMMI reiterated the WISeR Model will be evaluated based on accuracy and timeliness of prior authorization determinations, appeal rates for denied claims, provider and patient experience feedback and performance metrics for WISeR vendors, including processing speed; vendors may be removed if determinations are consistently delayed.

WISeR vendors will typically issue a coverage determination to the Medicare physician within three days of receiving the initial or resubmitted prior authorization request. For prior authorizations that require expedited review, a coverage decision will be provided to the Medicare physician within two days. CMS will also explore Gold Carding in mid-2026 to exempt providers with a high rate of approved requests from pre-payment review.

Radiology practices in affected states should begin preparing for documentation and workflow changes. For full details, refer to the WISeR Provider and Supplier Guide. Radiology practices should review and ensure compliance to avoid payment delays or denials.

Radiology providers in these states should be aware of the following:

• Prior Authorization Required: Services such as Percutaneous Vertebral Augmentation (PVA) and Epidural Steroid Injections will require prior authorization or face pre-payment medical review.
• Technology-Driven Oversight: CMS will use AI and machine learning tools to streamline and enhance the accuracy of medical necessity reviews. The vendors will be selected soon. Please monitor WISeR updates and FAQs regularly. 
• Operational Impact: Providers must submit documentation through designated channels (either to WISeR participants or Medicare Administrative Contractors) and adhere to specific timelines for review. The model relies on existing NCD and LCD coverage criteria. For each service there are coverage requirements and applicable codes to support medical necessity.
• Appeals and Exemptions: The guide outlines pathways for resubmissions, peer-to-peer reviews, and appeals, along with criteria for exemptions.
• Documentation Requirements: Detailed CPT/HCPCS and ICD-10 codes and service-specific documentation guidelines are provided in the appendices of the guide.

For more information about the Wiser Model or questions, contact Alicia Blakey, ACR Principal Economic Policy Analyst.