WellLink Health Alliance Expresses Concerns with CMS’s WISeR Model

Ohio is among just six states selected to take part in a new federal pilot program that could significantly alter how Medicare services are reviewed and reimbursed. Beginning Jan. 1, 2026, the Centers for Medicare & Medicaid Services (CMS) will launch the Wasteful and Inappropriate Services Reduction (WISeR) model, designed to curb Medicare spending by targeting services deemed to have little or no clinical benefit.

While WellLink Health Alliance supports efforts to reduce waste, fraud and abuse, the model raises serious concerns about potential care delays, administrative burdens and inappropriate denials for patients and providers.

In addition to Ohio, this six-year voluntary program will operate in five other states: Arizona, New Jersey, Oklahoma, Texas, and Washington. Providers in these states will be required to submit a prior authorization claim or be subject to review prior to receiving payment, leading WISeR to be seen as an involuntary burden on providers and Medicare beneficiaries.

Each participating state will partner with a different technology vendor to support CMS in implementing the WISeR model. For Ohio, CMS has selected Innovaccer.

AHA Reiterates Concerns About the WISeR Model

In a letter to Abe Sutton, JD, deputy administrator and director of CMS, the American Hospital Association (AHA) urged CMS to delay implementation of the WISeR model by at least six months.

The letter, which WellLink supports, outlined recommendations intended to ensure waste is reduced without creating inappropriate barriers to patient care or administrative burdens for providers.

AHA’s key recommendations include:

• Vendor payment methodology: Under WISeR, vendors would earn 10–20% of savings from denied claims, creating a profit motive to deny medically necessary care. This payment model risks replacing physician judgment with financial bias.  
• Appeal rights: Patients under original Medicare would not have the same right to appeal prior authorization denials as Medicare Advantage beneficiaries. This could leave patients without recourse to challenge inappropriate denials, especially those based on AI-driven decisions.
• Guardrails on artificial intelligence: The model relies heavily on AI and machine learning to decide medical coverage. Without strong guardrails, these tools may override individual patient circumstances or favor cost savings over clinical appropriateness.
• Adequate vendor oversight: CMS plans to use vendors that already manage prior authorization for Medicare Advantage plans, despite a history of inappropriate denials identified by federal oversight agencies. AHA recommends requiring public transparency into the algorithms used and disclosure of the exact coverage rule and corresponding clinical information relied upon in issuing a denial to providers and patients.
• Scope: AHA members expressed concern about the prospect that the WISeR model could be expanded beyond the specific services identified. Given the enormous disruptions that prior authorization can have on patient access to care and provider administrative burden, AHA urges the administration to refrain from increasing the number of states or adding new services until after the model has concluded and been subject to a thorough review.
• Programmatic evaluation: CMS has not specified how the program will be evaluated. To promote transparency, AHA recommends CMS clearly identify how it will evaluate success and suggests a quarterly progress report. 
• Consistency with prior authorization reform technology: AHA urges CMS to mandate that vendors participating WISeR support Fast Healthcare Interoperability Resources-enabled APIs, consistent with the Interoperability and Prior Authorization Final Rule (CMS-0057-F).
• Implementation timeline: Launching by Jan. 1, 2026, leaves insufficient time for hospitals to integrate systems, train staff, and test workflows. Without a delay of at least six months, the WISeR model could delay care for Medicare patients, especially those with chronic or complex conditions, increase administrative costs for hospitals already facing workforce shortages, and undermine clinical decision-making through profit-driven or automated denials.

AHA emphasized that delaying the implementation of WISeR would allow time to address these concerns. The organization also recommended that CMS establish an operations and testing period during which claims would not be denied due to WISeR model processes, allowing vendors and physicians to test the technologies and identify any unforeseen issues that could affect patient care.

As the pilot launch date approaches, key questions remain about how vendor contracts will be finalized, how provider workflows will adapt, and whether the model will achieve its goals or introduce new challenges for patients and providers.

On Nov. 7, six Democrats in the U.S. House, including Ohio Rep. Greg Landsman, introduced new legislation that would roll back the WISeR model amid mounting concerns. To view WellLink Health Alliance’s policy statement on the WISeR model, visit the organization’s Policy & Advocacy page.