The good news is: the federal government is finally working with Medicare (Dis)Advantage private insurers to reign in their onerous and downright silly (but lucrative for them) prior authorization requirements. Unfortunately, at the same time, the Center for Medicare and Medicaid Services (CMS) is introducing prior authorization's evil twin, the Wasteful and Inappropriate Service Reduction Model (WISeR), for Traditional Medicare clients. The six-year "pilot" model is to go into effect in six states in 2026. Unfortunately, my home state of Washington is among the six states (others are New Jersey, Ohio, Oklahoma, Texas, and Arizona). Those of us who have, until now, been able to avoid Medicare Advantage and its prior authorization hell, not to mention our own PeaceHealth's version of ACOReach/Direct Contracting Entity, into which many Traditional Medicare clients were involuntarily thrown, will soon be victims of a pilot project akin to being injected with infected cells from patients with necrotizing fasciitis. Want to kill Traditional Medicare? Use the risibly named WISeR Model.

You can review the CMS provided overview of the WISeR Model here, before going any farther. If you are already in Medicare (Dis)Advantage, you are already mired in the privatized medicine prior authorization scheme. So this article applies to you only in retrospect.  

As I read the overview, I noted that ostensibly, providers and suppliers of Medicare services are offered the "choice" of submitting their claims in various categories, not all of which are outlined in the WISeR Model fact sheet. The "choice" is essentially a false one and the following set off alarm bells.

"Providers and suppliers for people with Original Medicare in selected regions will have the choice of submitting a prior authorization request for the model’s selected items and services or go through a post- service/pre-payment medical review. Those that choose the prior authorization route may either submit the prior authorization request (a) directly to the model participant or (b) to their Medicare Administrative Contractor (MAC) that will forward the request to the model participant. If they opt not to submit a request for an included service, their claim will be subject to medical review by the model participant to ensure the delivered service met Medicare coverage, coding, and payment criteria prior to payment."

Roughly translated this means the provider's claim will be subject to medical review whether they "choose" to submit before providing the service or to provide the service and then hope that the claim will be paid based upon certain criteria. Either blocked up front, or not subsequently reimbursed; this is a classic example of a dilemma (one might even posit a false dilemma) presented as offering you a choice of options, neither of which is desirable.  

The so-called fact sheet mentions several services that will receive this further scrutiny for fraud, waste, and abuse without going into detail:

-Skin and tissue substitutes

-Electrical nerve stimulators

-Knee arthroscopy for knee osteoarthritis

It takes some digging, but the Federal Register contains the entirety of the text that establishes the pilot program. Clicking here will bring you to the document (Medicare Program; Implementation of Prior Authorization for Select Services for the Wasteful and Inappropriate Services Reduction (WISeR) Model) wherein the complete list of suspect services to be scrutinized can be found - 17 in all. So if your physician deems any of these 17 services to be necessary for YOU, it will mean that private-sector, third parties will be second-guessing his/her professional call, as in "prior authorization." And the second-guessers [again private sector companies] will be paid on a percentage of money "saved" - or, as may come to mind, claims denied. 

"Participants will be rewarded based on the effectiveness of their technology solutions for reducing spending on medically unnecessary or non-covered services. For each selected service, participants will receive a percentage of the reduction in savings that can be attributed to their reduction of wasteful or inappropriate care."

However, it's not the "wasteful or inappropriate care" that is causing massive losses in the Medicare Trust Fund, it is the continuation of Medicare (Dis)Advantage which has stolen hundreds of billions of dollars from Medicare since its inception back with Bush II. Subsequent appendages to Medicare, such as Direct Contracting Entities, ACO Reach and now this sinister encroachment on Traditional Medicare, called the WISeR Model, only add to the thievery. Medicare (Dis)Advantage is the real fraud, but since it lines the pockets of private corporations, it is OK in our present kleptocracy.  

Since millions of Traditional Medicare clients will be affected by this WISeR Model, thousands of physicians will be drawn into the fray, spending considerable amounts of their time and psychic energy defending their treatment choices. Whether on the phone, writing emails, or sending faxes, they will  spend valuable time arguing against the uninformed or badly informed (either by purpose or ignorance) insurance monitors who are acting with one thing in mind: MAKING MONEY. Patient care be damned. I wrote about the trauma already experienced by these physicians last year in my article Moral Injury Links Medicare Advantage Physicians To Combat Veterans. This JAMA article, published prior to the appearance of the WISeR Model, is also especially informative - "Salve Lucrum: The Existential Threat of Greed in US Health Care.