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Medicare is preparing to launch a pilot program that will require millions of seniors to jump through a new hoop before they can receive certain medical services.
Known as the Wasteful and Inappropriate Service Reduction (WISeR) model, it will require prior authorization for 17 services that are currently covered by Medicare. In other words, health care providers will have to request approval from Medicare before their patients can receive those services.
Technically, this prior authorization is voluntary, but providers who don’t obtain it will be subject to a medical review before Medicare pays them for their role in the services. The review “may involve requests for documentation to support the medical necessity of the targeted item or service.”
The six-year pilot program starts Jan. 1, 2026, in six states. It will affect people with Original Medicare, which is the type of Medicare coverage offered directly by the federal government.
The other type of Medicare coverage, Medicare Advantage plans, are offered by private insurance companies that contract with the government. These plans won’t be affected by the WISeR program, though.
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Why Medicare is cracking down
The goal of Wasteful and Inappropriate Service Reduction is to “help protect American taxpayers” by “helping patients and providers avoid unnecessary or inappropriate care,” according to the government.
The 17 affected services are commonly overused or historically have had a higher risk of waste, fraud and abuse, according to the Lown Institute, a health care think tank.
In an announcement about WISeR, Abe Sutton, director of the federal Centers for Medicare and Medicaid Services’ Innovation Center, said:
“Low-value services, such as those of focus in WISeR, offer patients minimal benefit and, in some cases, can result in physical harm and psychological stress. They also increase patient costs, while inflating health care spending.”
Medicare spent $5.8 billion in 2022 on just 31 services that the Lown Institute describes as “low-value services that are more likely to harm than help patients.” According to federal data, these services were delivered at a rate of 71 per 100 Medicare patients.
Some of these procedures have been on lists of low-value care that providers should avoid for over a decade.
One example is vertebroplasty, a procedure that involves injecting cement into the spine to treat spinal fractures. From 2020 to 2023, U.S. hospitals performed 100,000 vertebroplasties that met criteria for overuse, according to Lown Institute data.
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The 17 services on the WISeR list
The medical services affected by the WISeR pilot are:
- Electrical nerve stimulators
- Sacral nerve stimulation for the treatment of urinary incontinence
- Phrenic nerve stimulator (a device used to help patients with hypoventilation breath)
- Deep brain stimulation for the treatment of essential tremor and Parkinson’s disease
- Vagus nerve stimulation
- Surgically induced lesions of nerve tracts (a procedure that involves destroying nerve tissue, typically to treat pain)
- Hypoglossal nerve stimulation for the treatment of obstructive sleep apnea
- Epidural steroid injections for pain management, excluding facet joint injections
- Percutaneous vertebral augmentation, aka vertebroplasty (a procedure that involves injecting bone cement into vertebrae), for the treatment of a vertebral compression fracture
- Cervical fusion surgery
- Arthroscopic lavage and arthroscopic debridement for the knees of people with osteoarthritis, aka knee arthroscopy (a procedure that involves removing damaged cartilage or bone from knees)
- Incontinence control devices
- Diagnosis and treatment of impotence
- Percutaneous image-guided lumbar decompression for spinal stenosis
- Skin and tissue substitutes
- Application of bioengineered skin substitutes to chronic non-healing wounds on lower limbs
- Wound application of cellular and/or tissue-based products for lower limbs
The 6 states affected
The states involved in the pilot program are:
- Arizona
- New Jersey
- Ohio
- Oklahoma
- Texas
- Washington
A total of 6.4 million people in these states are on Original Medicare, according to an analysis by the consulting firm McDermott+. So they could be affected if they sought one of the 17 services during the pilot period.
To learn more about overused medical services analyzed by the Lown Institute, check out “These U.S. Hospitals Actually Avoid Unnecessary Tests.”
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