WISeR
Wasteful and Inappropriate Service Reduction (WISeR) Model
The Wasteful and Inappropriate Service Reduction (WISeR) Model helps protect American taxpayers by leveraging enhanced technologies, such as Artificial Intelligence (AI) and Machine Learning (ML), along with human clinical review, to ensure timely and appropriate Medicare payment for select items and services. The voluntary model encourages care navigation, encouraging safe and evidence-supported best practices for treating people with Medicare.
Innovation
Leveraging enhanced technologies, such as Artificial Intelligence (AI) and Machine Learning (ML), along with human clinical review, to expedite and improve the prior authorization review process for a pre-selected set of services.
The Problem
Waste in health care can not only harm patients but also contributes to up to 25% of health care spending in the United States. Wasteful, low-value services often have limited clinical evidence of effectiveness, may not align with an individual’s specific health condition or needs, or can lead to complications and further unneeded services.
The Solution
The WISeR Model helps reduce clinically unsupported care by working with companies experienced in using enhanced technologies to expedite and improve the review process for a pre-selected set of services that are vulnerable to fraud, waste and abuse.
Expected Outcomes
The WISeR Model helps ensure people with Medicare receive the most appropriate care that supports the best health outcomes while decreasing costs and easing administrative burden on providers and suppliers who go through the prior authorization process.
Strategy
The WISeR Model empowers patients to partner with their health care providers on the most clinically appropriate care plan; protects the taxpayer by decreasing fraud, waste and abuse; and focuses providers on care that has the most impact on the well-being of people with Medicare.
Model Goals
- Promote evidence-based prevention by introducing clinical review with enhanced technology to ensure patients are receiving the most appropriate and effective care
- Empower people to achieve their health goals by setting the stage for beneficiaries partnering with their clinicians on the most effective care plans
- Drive choice and competition for people by applying new tools in Original Medicare and incentivizing participating companies to deliver fast, accurate, transparent prior authorization decisions
Patient Eligibility
People with Original Medicare receiving select nonemergent services.
- Enrolled in Original Medicare
- Receiving select items and services such as skin substitutes, knee arthroscopy, or electrical nerve stimulation
Provider Eligibility
Providers and suppliers delivering selected services in participating states.
- Located in New Jersey, Ohio, Oklahoma, Texas, Arizona, or Washington
- Delivering services in Hospital Outpatient Departments (HOPDs), Ambulatory Surgery Centers (ASCs), office, or home settings
Care Categories
Dermatology
Orthopedics
Pain Management
Program Benchmarks & Thresholds
financial
operational
population
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