In a dramatic shift that could reshape the landscape of Medicare reimbursement, CMS has announced the WISeR model—bringing prior authorization into traditional Medicare fee-for-service (FFS) for the first time. Launching January 1, 2026, this 6-year pilot will require prior authorization for select outpatient services in six states, using technology-assisted reviews and third-party administrators. While commercial plans and Medicare Advantage have long relied on prior auth as a utilization management tool, this expansion marks a fundamental change in how providers interact with FFS Medicare.
In this Office Hours panel, we’ll break down what providers, revenue cycle leaders, and compliance officers need to know right now. We’ll explore the services impacted, how the model works, and the potential benefits—and serious risks—this introduces for workflow, denials, and patient access. We’ll also examine CMS’s use of AI and automation, the gold-card exemption pathway, and what this might signal for future nationwide implementation. Whether you operate in a WISeR test state or not, this model will be a bellwether for things to come.
Panelists:
- Stephanie Cheng, Associate Director of Client Success
- Stephanie Solich, VP of Revenue Cycle & Strategy, Midwest Region
- James Beacham, VP of Revenue Cycle & Strategy, Southeast Region
Learning Objectives
- Understand the scope and mechanics of the WISeR model and what it means for providers operating under Medicare FFS, including the states and services impacted.
- Evaluate the operational implications of technology-driven prior authorization, including AI-assisted determinations, new documentation workflows, and the role of third-party contractors.
- Identify proactive strategies for compliance and risk mitigation, including participation in education programs, preparing for pre-payment reviews, and qualifying for gold-card exemptions.
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