Key Targets of the WISeR Program

In the Centers for Medicare & Medicaid Services’ (CMS’s) ongoing attempts to conquer fraud, waste, and abuse, it launched the WISeR (Wasteful and Inappropriate Service Reduction) Model as of the start of this year, using technology-enabled prior authorization for a set of items/services CMS believes are vulnerable to such issues. It’s currently limited to six states: Texas, Arizona, Washington, New Jersey, Ohio, and Oklahoma. Implementation details/operational steps are spelled out in CMS model materials. This matters for providers because it changes front-end billing workflows (documentation, ordering, timing, and appeals posture) for impacted services and sites of care.

The WISeR model reportedly is meant to combat fraud, and will employ private companies to test if artificial intelligence (AI) can handle the prior authorization process used to determine if a recipient of Medicare is eligible for funding for a health service. The model specifically will look at services CMS considers to be “particularly vulnerable to fraud, waste, and abuse.”

If you operate in WISeR states, treat it like a new “mini-utilization management” layer for Medicare; build a same-day documentation/PA (physician assistant) packet process, and track denial reasons from day one.

What services are included in the new initial phase of the WISeR program? My list here is not comprehensive:

Nerve Stimulator Implants and Neuromodulation

• These are high-cost implantable or invasive neurostimulation procedures: Electrical nerve stimulators (NCD 160.7);
• Sacral nerve stimulation for urinary incontinence (NCD 230.18);
• Phrenic nerve stimulator (NCD 160.19);
• Deep brain stimulation (Parkinson’s disease, essential tremor) (NCD 160.24); and
• Vagus nerve stimulation (NCD 160.18).

These alone hit neurology, neurosurgery, urology, and pain management heavily.

Pain Management Procedures

These are some of the most targeted pain interventions nationwide:

• Epidural steroid injections;
• Induced lesions of nerve tracts;
• Percutaneous image-guided lumbar decompression; and
• Arthroscopic lavage and debridement for osteoarthritic knee.

These services are heavily utilized and frequently audited by Unified Program Integrity Contractors (UPICs), Recovery Audit Monitors (RACs), and Medicare Administrative Contractors (MACs) already.

Spine and Orthopedic Surgery Procedures

Major spine and orthopedic procedures now subject to WISeR prior authorization include:

• Cervical fusion procedures (excluding certain OPD-covered codes);
• Lumbar decompression procedures; and
• Vertebral augmentation procedures.

This is significant because these are high-value, high-volume services with significant reimbursement exposure.

Sleep Apnea Implant Procedures

Specifically targeted are:

• Hypoglossal nerve stimulation for obstructive sleep apnea.

This is a rapidly growing implant procedure with aggressive utilization growth.

Urology and Genitourinary Procedures/Devices

These include:

• Incontinence control devices (NCD 230.10); and
• Diagnosis and treatment of impotence (NCD 230.4);

These involve implantable devices and surgical interventions.

Wound Care: Skin Substitutes and Tissue Products

This is one of the most heavily targeted areas, and one you frequently litigate:

• Bioengineered skin substitutes for chronic wounds;
• Cellular and tissue-based products (CTPs); and
• Skin and tissue substitute applications to lower-extremity wounds;

These products have been the subject of massive UPIC and U.S. Department of Justice (DOJ) enforcement actions already.

So, why did CMS choose these services, and why should providers be concerned?

CMS selected services that are:

• High-cost;
• Elective or non-emergent;
• Vulnerable to fraud or overuse;
• Already subject to coverage criteria (NCDs/LCDs); and
• Frequently audited or denied historically.

CMS explicitly stated that the model targets services that are “known source(s) of potential waste … vulnerable to fraud, waste, and abuse … (and) costly, elective services.”

Critical legal implication most providers miss includes the following:

If providers do NOT submit prior authorization:

• Their claim will automatically be flagged;
• Subject to pre-payment medical review;
• Potentially denied before payment;
• Or delayed significantly

This effectively creates de facto mandatory prior authorization, even though CMS calls it “voluntary.”

CMS also confirmed it will expand services over time.