How Hospitals Will Need to Work WISeR in 2026

The following is a guest article by Carol Howard, BSN, MBA, Vice President of Innovation and Adoption at Janus Health

Hospitals are entering another period of uncertainty as the Centers for Medicare & Medicaid Services (CMS) launches the Wasteful and Inappropriate Services Reduction Model in 2026. 

Many organizations are already managing rising denial volumes, staffing shortages, and increasing documentation requirements that place continued strain on clinical as well as revenue cycle teams. WISeR introduces additional operational complexity during a period when even minor errors can result in reimbursement delays or denials.

While medical-necessity and documentation standards are not new, WISeR requires hospitals in participating states to meet these requirements through a new prior authorization process for select services. This change increases operational demands on already constrained teams.

Yet this model also creates an opportunity for organizations to strengthen internal processes. Data and automation can help streamline compliance workflows, improve documentation consistency, and reduce administrative burden on clinical and revenue cycle teams.

Hospitals that take proactive steps to modernize and automate key tasks will be better prepared for the precision and transparency that WISeR expects. This preparation supports more predictable reimbursement and greater operational resilience in the years ahead.

Reducing Low-Value Care

A recent study found that Medicare spends about $3.6 billion each year on services identified as low-value, with beneficiaries paying an additional $800 million out of pocket, bringing the total spending on care that offers limited or no clinical benefit to $4.4 billion. This burden affects patients who may experience unnecessary procedures and increased costs. It also affects hospitals that face more intense scrutiny for high-cost or low-evidence interventions.

The WISeR Model, as outlined by CMS, directly addresses these concerns by establishing an earlier, more structured review process for designated services with a documented history of overuse, questionable necessity, or inconsistent documentation. 

The CMS overview notes that model participants will use AI and machine learning to support these reviews, with licensed clinicians confirming final decisions. This shift introduces operational changes that will affect how hospitals prepare, document, and submit claims for selected services.  Model participants are compensated based in part on their ability to reduce or deny services that do not meet coverage criteria, which underscores the importance of thorough documentation and accurate submission.

Spotlight on Hospital Revenue Cycle Operations

Existing medical-necessity requirements continue to apply, but hospitals in participating states must now follow a new prior authorization process for 17 targeted procedures, including nerve stimulation devices, select orthopedic and spine interventions, certain pain management procedures, and specific wound care applications. CMS reported that it selected these services based on known patterns of overuse or inconsistent evidence of clinical benefit.

For each of these claims, hospitals must choose either pre-service prior authorization or post-service prepayment review. Both paths require complete and accurate documentation to support medical necessity. Claims that do not meet these expectations may be delayed or denied, which can strain cash flow and increase administrative work.

Hospitals will benefit from implementing proven AI-enabled workflows that clearly flag when a scheduled procedure falls within the WISeR set, thereby reducing revenue-cycle risks once the model is in effect. This ensures that staff collect required information early in the process and that clinicians understand the coverage criteria needed for a strong submission.

How WISeR Differs from Other Prior Authorization Reforms

While CMS is increasing scrutiny, many commercial payers have committed to easing the prior authorization process by 2027. Their focus includes reducing the volume of services requiring review, expanding real-time automated decisions, and integrating more standardized electronic submission processes. These planned reforms are designed to improve transparency, reduce provider burden, and speed up access to care.

WISeR represents a different direction for selected Medicare fee-for-service procedures. The model strengthens oversight for high-cost services with variable documentation and utilization patterns. As such, hospitals will operate in a dual environment where some authorizations become simpler, but a subset of services will require more rigorous justification.

This divergence underscores the importance of flexible workflows that can support different authorization pathways without increasing complexity or burden for clinical and operational staff.

Preparing for Dual Path Workflows

Revenue cycle leaders can take several steps to prepare.

First, hospitals should audit current volumes of WISeR-targeted services and identify which departments drive the majority of these procedures. High-volume specialties, such as orthopedics, neurology, pain management, and wound care, may require targeted education and workflow adjustments. Review OIG audit reports for WISeR-targeted services to identify the specific compliance and utilization concerns that prompted selection. Also, confirm which services have session limits and whether associated anesthesia typically meets medical-necessity standards.

Second, hospitals should review historical trends in denials related to medical necessity. Understanding these prior gaps can help guide staff training and reduce future risk. CMS emphasizes that documentation must comply with existing Medicare coverage policies and clearly demonstrate that each service is clinically appropriate for the patient’s condition. Providers should also confirm with their MAC whether any supplemental requirements apply. Because AI tools will be reviewing this documentation, it is essential to be thorough and precise. All aspects of the LCD/NCD—including clinical criteria and any required supporting evidence—should be explicitly addressed.

Third, teams should establish clear, structured workflows for traditional Medicare cases. Staff must understand when prior authorization is required, what documentation is necessary for a complete review, how to manage redetermination, and where and how to submit requests. For cases managed through post-service review, comprehensive documentation remains essential to support payment.

AI Automation and Analytics Essential to Readiness

CMS notes that model participants will use advanced technology to expedite decision-making and reduce unnecessary utilization. Hospitals that adopt complementary internal tools can reduce manual work and strengthen compliance. Automation supports accurate submission, timely status tracking, and consistent documentation practices, and AI-enabled analytics help leaders identify variation, monitor affirmation rates, and prepare for potential exemption through gold carding, which is the agency’s exemption for providers who consistently achieve a 90% affirmation rate for selected services.

The WISeR Model reflects a growing national focus on reducing low-value care. It also reflects a broader shift toward transparency, evidence-based practice, and accountability. Hospitals that prepare now through operational discipline, cross-functional training, and strategic use of technology and AI automation will be positioned to navigate WISeR successfully and support timely, appropriate patient care.

About Carol Howard

With over two decades of experience in healthcare revenue cycle management and clinical operations, Carol brings a unique blend of nursing expertise, operational efficiency, and financial leadership to her role as VP of Innovation and Adoption at Janus Health. Throughout her career, she has translated data insights into measurable improvements—optimizing workflows, reducing denials, and implementing innovative tools that drive financial performance. Carol is passionate about empowering healthcare professionals through education and technology. She has led initiatives that strengthen staff capability, foster best-practice adoption, and embed continuous improvement into hospital culture. At Janus Health, she partners with customers to deliver tangible results through adoption strategies, engagement frameworks, and measurable performance outcomes. A registered nurse, Carol earned her Bachelor of Science in Nursing from the University of South Carolina and her MBA from Brenau University in Georgia.

The following is a guest article by Carol Howard, BSN, MBA, Vice President of Innovation and Adoption at Janus Health

Hospitals are entering another period of uncertainty as the Centers for Medicare & Medicaid Services (CMS) launches the Wasteful and Inappropriate Services Reduction Model in 2026. 

Many organizations are already managing rising denial volumes, staffing shortages, and increasing documentation requirements that place continued strain on clinical as well as revenue cycle teams. WISeR introduces additional operational complexity during a period when even minor errors can result in reimbursement delays or denials.

While medical-necessity and documentation standards are not new, WISeR requires hospitals in participating states to meet these requirements through a new prior authorization process for select services. This change increases operational demands on already constrained teams.

Yet this model also creates an opportunity for organizations to strengthen internal processes. Data and automation can help streamline compliance workflows, improve documentation consistency, and reduce administrative burden on clinical and revenue cycle teams.

Hospitals that take proactive steps to modernize and automate key tasks will be better prepared for the precision and transparency that WISeR expects. This preparation supports more predictable reimbursement and greater operational resilience in the years ahead.

Reducing Low-Value Care

A recent study found that Medicare spends about $3.6 billion each year on services identified as low-value, with beneficiaries paying an additional $800 million out of pocket, bringing the total spending on care that offers limited or no clinical benefit to $4.4 billion. This burden affects patients who may experience unnecessary procedures and increased costs. It also affects hospitals that face more intense scrutiny for high-cost or low-evidence interventions.

The WISeR Model, as outlined by CMS, directly addresses these concerns by establishing an earlier, more structured review process for designated services with a documented history of overuse, questionable necessity, or inconsistent documentation. 

The CMS overview notes that model participants will use AI and machine learning to support these reviews, with licensed clinicians confirming final decisions. This shift introduces operational changes that will affect how hospitals prepare, document, and submit claims for selected services.  Model participants are compensated based in part on their ability to reduce or deny services that do not meet coverage criteria, which underscores the importance of thorough documentation and accurate submission.

Spotlight on Hospital Revenue Cycle Operations

Existing medical-necessity requirements continue to apply, but hospitals in participating states must now follow a new prior authorization process for 17 targeted procedures, including nerve stimulation devices, select orthopedic and spine interventions, certain pain management procedures, and specific wound care applications. CMS reported that it selected these services based on known patterns of overuse or inconsistent evidence of clinical benefit.

For each of these claims, hospitals must choose either pre-service prior authorization or post-service prepayment review. Both paths require complete and accurate documentation to support medical necessity. Claims that do not meet these expectations may be delayed or denied, which can strain cash flow and increase administrative work.

Hospitals will benefit from implementing proven AI-enabled workflows that clearly flag when a scheduled procedure falls within the WISeR set, thereby reducing revenue-cycle risks once the model is in effect. This ensures that staff collect required information early in the process and that clinicians understand the coverage criteria needed for a strong submission.

How WISeR Differs from Other Prior Authorization Reforms

While CMS is increasing scrutiny, many commercial payers have committed to easing the prior authorization process by 2027. Their focus includes reducing the volume of services requiring review, expanding real-time automated decisions, and integrating more standardized electronic submission processes. These planned reforms are designed to improve transparency, reduce provider burden, and speed up access to care.

WISeR represents a different direction for selected Medicare fee-for-service procedures. The model strengthens oversight for high-cost services with variable documentation and utilization patterns. As such, hospitals will operate in a dual environment where some authorizations become simpler, but a subset of services will require more rigorous justification.

This divergence underscores the importance of flexible workflows that can support different authorization pathways without increasing complexity or burden for clinical and operational staff.

Preparing for Dual Path Workflows

Revenue cycle leaders can take several steps to prepare.

First, hospitals should audit current volumes of WISeR-targeted services and identify which departments drive the majority of these procedures. High-volume specialties, such as orthopedics, neurology, pain management, and wound care, may require targeted education and workflow adjustments. Review OIG audit reports for WISeR-targeted services to identify the specific compliance and utilization concerns that prompted selection. Also, confirm which services have session limits and whether associated anesthesia typically meets medical-necessity standards.

Second, hospitals should review historical trends in denials related to medical necessity. Understanding these prior gaps can help guide staff training and reduce future risk. CMS emphasizes that documentation must comply with existing Medicare coverage policies and clearly demonstrate that each service is clinically appropriate for the patient’s condition. Providers should also confirm with their MAC whether any supplemental requirements apply. Because AI tools will be reviewing this documentation, it is essential to be thorough and precise. All aspects of the LCD/NCD—including clinical criteria and any required supporting evidence—should be explicitly addressed.

Third, teams should establish clear, structured workflows for traditional Medicare cases. Staff must understand when prior authorization is required, what documentation is necessary for a complete review, how to manage redetermination, and where and how to submit requests. For cases managed through post-service review, comprehensive documentation remains essential to support payment.

AI Automation and Analytics Essential to Readiness

CMS notes that model participants will use advanced technology to expedite decision-making and reduce unnecessary utilization. Hospitals that adopt complementary internal tools can reduce manual work and strengthen compliance. Automation supports accurate submission, timely status tracking, and consistent documentation practices, and AI-enabled analytics help leaders identify variation, monitor affirmation rates, and prepare for potential exemption through gold carding, which is the agency’s exemption for providers who consistently achieve a 90% affirmation rate for selected services.

The WISeR Model reflects a growing national focus on reducing low-value care. It also reflects a broader shift toward transparency, evidence-based practice, and accountability. Hospitals that prepare now through operational discipline, cross-functional training, and strategic use of technology and AI automation will be positioned to navigate WISeR successfully and support timely, appropriate patient care.

About Carol Howard

With over two decades of experience in healthcare revenue cycle management and clinical operations, Carol brings a unique blend of nursing expertise, operational efficiency, and financial leadership to her role as VP of Innovation and Adoption at Janus Health. Throughout her career, she has translated data insights into measurable improvements—optimizing workflows, reducing denials, and implementing innovative tools that drive financial performance. Carol is passionate about empowering healthcare professionals through education and technology. She has led initiatives that strengthen staff capability, foster best-practice adoption, and embed continuous improvement into hospital culture. At Janus Health, she partners with customers to deliver tangible results through adoption strategies, engagement frameworks, and measurable performance outcomes. A registered nurse, Carol earned her Bachelor of Science in Nursing from the University of South Carolina and her MBA from Brenau University in Georgia.