Medicare to Test Enhanced Technology Utilization Review in Texas
By Phil West

The Texas Medical Association joined a growing chorus across organized medicine raising serious concerns with the patient impact and physician burdens potentially posed by a new Medicare prior authorization pilot, set to start Jan. 1, 2026. 

Per the CMS website, the Wasteful and Inappropriate Service Reduction (WISeR) Model, to be run by the Centers for Medicare & Medicaid Services (CMS) in Texas and five other states, “will help protect American taxpayers by leveraging enhanced technologies, such as artificial intelligence (AI) and machine learning, along with human clinical review, to ensure timely and appropriate Medicare payment for select items and services.” 

Although not officially part of the proposed 2026 Medicare physician fee schedule, TMA took the opportunity in its comments on the payment proposal to implore CMS to pause WISeR’s implementation pending additional stakeholder input, more thorough analysis, and clearer guidelines for physicians and patients. 

“This model has potential to add unanticipated and substantial administrative burden to physician practices,” TMA President Jayesh “Jay” Shah, MD, wrote in the Sept. 12 letter to CMS. 

TMA staff note as a Center for Medicare and Medicaid Innovation (CMMI) program, pilots like WISeR can be initiated without going through the formal rulemaking process. On the other hand, such demonstrations also can more easily be modified or canceled during the test period. 

CMS will use WISeR to test the ability of enhanced technology such as AI to expedite the utilization review process – primarily prior authorization – for a select group of Medicare services the agency CMS has identified as “particularly vulnerable to fraud, waste, and abuse, or inappropriate use,” such as skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy for knee osteoarthritis. CMS notes exceptions for inpatient-only services, emergency services, and “services that would pose a substantial risk to patients if significantly delayed.”   

The full list of impacted services is included in the Federal Register notice detailing the program.   

Vendors selected by WISeR to perform enhanced technology utilization review will be compensated based on a percentage of savings generated via those decisions – raising additional apprehensions about incentives Dr. Shah said “allow the vendors to be paid according to the savings accrued, which is a perverse incentive in health care since it will likely result in increased denials.”  

Physicians submitting Medicare payment requests for items and services on the WISeR list will choose between submitting prior authorization requests – either directly to vendors or to the Medicare administrative contract fielding requests for vendors – or having the claim be subject to prepayment medical review, CMS noted its initial June 27 press release. 

Per CMS’ WISeR fact sheet, the postservice, prepayment medical review by the vendor would be done “to ensure the delivered service met Medicare coverage, coding, and payment criteria prior to payment.”  

The press release also specified CMS may include a pathway in the future allowing those with “strong compliance records” to qualify for review exemptions.  

In a separate letter to CMS, the American Medical Association in July also urged delaying WISeR’s start, concerned it could be a prelude to future expanded mandatory prior auth requirements for Medicare. The Medical Group Management Association also has expressed concerns about the program.  

Among a list of recommendations, AMA suggested instead: 

• Making WISeR participation voluntary for physicians; 

• Having CMS “publish transparent, clinically valid criteria for which services require [prior authorization] and how quality process measures are applied to participants’ payments;” and 

• Ensuring approved prior authorization under WISeR is “a binding guarantee of payment when services are provided as authorized and medically necessary, without retroactive denials based on technicalities.” 

Learn more about TMA’s federal advocacy work and its work to preserve practice viability statewide during the 2025 Texas legislative session.