The Wasteful and Inappropriate Service Reduction (WISeR) Model represents a massive shift in how CMS handles claims. By leveraging advanced technology and AI, CMS aims to review the medical necessity for select items and services at the beginning of the claims process rather than chasing down errors later.¹
The goal? To ensure Medicare participants receive the most appropriate care to support the best health outcomes, while simultaneously decreasing costs and easing the administrative burden of prior authorization.¹
This innovative model is currently being tested on specific items and services, with skin and tissue substitutes being a primary focus and a direct impact to wound care providers. To start, the pilot is launching in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington.
Cutting the Fat: How WISeR Targets Waste Without Sacrificing Care
The problem is clear: Up to 25% of U.S. healthcare spending is considered wasteful, with Medicare spending billions on low-value services.² With the WISeR initiative, CMS aims to reduce fraud, waste, and abuse while ensuring clinically appropriate care is delivered.
The WISeR Model is designed to use a hybrid approach of AI and machine learning alongside human clinical review to streamline prior authorization documentation. This offers a significant upside for providers:
- Faster Payments: Participating providers can receive pre-approval for payment before providing a service.
- Rapid Turnaround: The expected turnaround time for review is 72 hours or less.
- Payment Certainty: As long as the documentation and claim are correct, providers will know in advance that they will be paid.
While this aims to ease the administrative burden, it dramatically increases the importance of accurate, rigorous documentation.
Skin Substitutes Under the Microscope: What’s Changing?
Skin and tissue substitutes for chronic non-healing wounds have been identified as a high-risk, high-spend area. Consequently, they are a target service under the WISeR Model, bringing both opportunities and challenges to wound care.
The application of bioengineered skin substitutes and cellular/tissue-based products (CTPs) is still fairly new. While many positive outcomes have been seen, it can be a pricey intervention with variable outcomes, making it highly vulnerable to misuse. However, the new 2026 CMS changes for skin substitute reimbursement should add more stability in this area alongside WISeR Model protocols.
Prior Authorization Gets a Tech Upgrade—Are You Ready?
The WISeR model essentially gives prior authorization a technology-driven makeover. Here is what providers need to anticipate:
- Tech-Driven Review: The process moves away from purely manual reviews to AI-driven checks with clinician oversight. This means your documentation needs to be structured in a way that is easily digestible by these systems.
- The “Gold Card” Incentive: There is potential for administrative relief. Providers who consistently demonstrate compliance and accurate documentation may receive exemptions or “gold card” status, allowing them to bypass certain review hurdles.
- Medical Necessity is King: Documentation standards are rising. It is no longer enough to state that a skin substitute was applied; you must prove medical necessity aligned with Local Coverage Determinations.
What Providers Should Do to prepare
The WISeR model’s emphasis on “medical necessity” and “waste reduction” means that subjective, text-based notes are a liability. To get paid within that 72-hour window, you need objective, defensible data. This is where technology, like Swift Medical, bridges the gap:
- Consistent Documentation: Swift’s AI-powered measurements provide precise surface area and depth tracking. This objective data helps illustrate whether a wound is stalling or progressing, providing evidence needed to justify the use of expensive skin substitutes.
- Visual Evidence: High-quality, calibrated imagery is the best defense against claim denials. Swift ensures that every claim is backed by visual proof of the wound’s status before and after treatment.
- Standardization: Swift helps standardize workflows across your organization, ensuring that every clinician is documenting to the standards required by the WISeR model.
- Advanced Imaging: Thermal and bacterial imaging take documentation one step further and provide insights beyond what the human eye can see.
The Bottom Line
The WISeR Model signals a future where reimbursement is tied strictly to data-proven outcomes. While it may influence future wound care innovation and policy, it also rewards providers who are organized and compliant. It is starting as a six-state pilot but it assuming success, it will see expansion in the future.
By leveraging Swift Medical, you can meet the documentation precision required by CMS, so that while the government cuts the waste, you don’t lose out on reimbursements for the critical care your patients need.
