What Happened?
In early July, CMS announced that they will be launching a new technology focused prior authorization process in six states to help combat fraud, waste and abuse in Traditional Medicare.

• CMS has highlighted that fraudulent or abusive billing practices, the provision of services with minimal clinical benefit and the use of riskier patient interventions when other options are available have all contributed to patient harm and unnecessary financial waste, indicating a need for the pilot program.

What is Changing?
Starting on January 1, 2026, six states will participate in a six-year prior authorization pilot program called the Wasteful and Inappropriate Services Reduction (WISeR Model) for 17 services.

The states included in the pilot program are:

• New Jersey
• Ohio
• Oklahoma
• Texas
• Arizona
• Washington

The WISeR Model will utilize technology-assisted prior authorization tools to validate proper documentation and medical necessity before approving services. No additional documentation will be required for this process. CMS emphasized that the key is ensuring the prior authorization step happens before services are provided to patients and claims are submitted.

Services included in the WISeR Model for prior authorization review are:

CMS has stated that the above services were chosen due to prior issues around FWA and patient safety concerns.

What do MSSP and ACO REACH Organizations Need to do Now?

1). ACO participants should expect closer scrutiny around what care gets delivered, when, and why.

• Even in value-based models, CMS is using tools like prior authorization through WISeR in Traditional Medicare and broader reforms in Medicare Advantage to flag services that don’t meet evidence-based or policy standards.

2). MSSP and ACO REACH organizations will need to tighten internal oversight.

• Organizations will need to reinforce care management, referral processes, and provider workflows to proactively catch services that may be non-compliant or non-covered before they result in denials, delays, or added financial risk.

3). The focus is shifting from meeting benchmarks to consistently delivering appropriate care.

• CMS is embedding medical necessity review earlier in the process, especially for services known to be overused, which puts more pressure on ACOs to manage utilization at the front end.

4). ACOs that act now will be better positioned to succeed.

• Aligning clinical pathways, staff training, and analytics with these expectations helps avoid disruption, capture savings, and build stronger credibility with CMS and payer partners.

How can COPE Health Solutions Help?

COPE Health Solutions has extensive experience and success in helping MSSP and ACO REACH organizations navigate through new CMS changes. With the new WISeR Model starting in less than six months, it’s vital that clients start preparing now for these changes and evaluate their current HER and UM system integration capabilities. Contact COPE Health Solutions today to learn how we’re assisting our clients and how we can partner to ensure your organization is prepared for this 2026 change.

Contact us at info@copehealthsolutions.com to learn more today.