forbes.com
CMS Launches AI-Driven Prior Authorization Program to Reduce Medicare Fraud
CMS launched the six-year WISeR (Wasteful and Inappropriate Service Reduction) model on June 27, 2025, using AI to expedite prior authorizations for 17 Original Medicare services in six states to reduce $60 billion in annual fraud and costs from low-value services.
- What are the immediate financial impacts and systemic changes resulting from CMS's implementation of the WISeR model for Original Medicare?
- The Centers for Medicare & Medicaid Services (CMS) launched the Wasteful and Inappropriate Service Reduction (WISeR) model on June 27, 2025, a six-year pilot program across six states to use AI to expedite prior authorization for 17 services vulnerable to fraud and abuse in Original Medicare. This aims to reduce Medicare's $60 billion annual fraud losses and costs from low-value services like percutaneous vertebral augmentation and knee arthroscopy, which cost $808 million in 2022.
- How does the WISeR model's use of AI and third-party contractors address concerns about fraud and waste while mitigating potential risks to providers and beneficiaries?
- WISeR targets specific Original Medicare services with high fraud rates or low value, aiming to improve efficiency and reduce costs. The program uses AI to streamline prior authorization, a process already existing in Original Medicare but expanded in 2020 and 2024. This initiative seeks to address significant financial losses resulting from fraudulent claims and inappropriate service utilization.
- What are the potential long-term consequences of the WISeR model on the structure and accessibility of Original Medicare, considering concerns about its resemblance to Medicare Advantage?
- WISeR's success hinges on balancing cost savings with potential provider burden and beneficiary access. The program's use of AI and third-party contractors raises concerns, requiring robust oversight to prevent unintended consequences and ensure fairness. Long-term effects on Original Medicare's structure and accessibility remain uncertain, demanding careful monitoring throughout the six-year pilot.
Cognitive Concepts
Framing Bias
The article's framing is generally positive towards the WISeR model, emphasizing its potential to combat fraud and waste. While acknowledging concerns, the positive aspects are highlighted more prominently, potentially influencing reader perception.
Language Bias
The language used is largely neutral, although phrases like "incredible number of discussions and questions" and "creative acronym" subtly inject a subjective tone. The description of fraud as "Medicare loses an estimated $60 billion each year" is impactful but remains factual.
Bias by Omission
The article focuses heavily on the WISeR model's goals and mechanics but omits discussion of potential negative consequences for providers or beneficiaries, such as increased administrative burden or delays in care. While acknowledging some concerns, a more in-depth exploration of potential downsides would improve balance.
False Dichotomy
The article presents a somewhat false dichotomy by framing the choice between Original Medicare and Medicare Advantage as an eitheor proposition. While the article acknowledges differences, it doesn't fully explore the possibility of WISeR influencing Original Medicare without completely mirroring Medicare Advantage.
Sustainable Development Goals
The WISeR model aims to reduce fraud, abuse, and waste in Medicare, including low-value care. By targeting wasteful spending, the model can free up resources for more effective and beneficial healthcare services, ultimately improving the quality of care for beneficiaries. The focus on reducing low-value services ensures that resources are directed towards treatments with demonstrable positive health outcomes.