Medicare picks participants for WISeR model, including radiologist-owned tech company
Medicare recently revealed participants in its controversial new pay model aimed at curbing unnecessary interventional radiology services. Meanwhile, House Democrats have introduced a bill to block the prior authorization pilot.
First introduced in June, the Wasteful and Inappropriate Service Reduction (or “WISeR”) initiative will begin on Jan. 1 across six states. The Centers for Medicare & Medicaid Services has recruited six technology firms, which will use artificial intelligence in to curb IR procedures it contends are subject to abuse.
Oklahoma will use Humata Health, a firm founded by “recovering radiologist” Jeremy Friese, MD, who said he had grown frustrated with the struggles of prior authorization.
“Humata’s core mission is to ensure that every patient receives the right care as quickly as possible,” Friese said in an announcement Nov. 7, after being named as a participant. “This is a defining opportunity to set a new standard—one where technology finally brings physicians and payers together—for the good of the patient.”
The American College of Radiology highlighted the participants in news update published Thursday. Others include:
- Texas (JH Novitas Medicare Administrative Contractor jurisdiction): Cohere Health Inc., a Boston-based company that provides “intelligent prior authorization as a springboard to better quality outcomes.”
- New Jersey (JH Novitas): Genzeon Corp., an Exton, Pennsylvania, AI and automation company with “deep engineering and data expertise, dedicated to serving the healthcare industry.”
- Oklahoma (JH Novitas): Humata Health, a Winter Park, Florida-based tech firm that combines automation, deep EHR integration and real-time payer connectivity to help eliminate friction and streamline the prior authorization process.
- Ohio (J15 CGS): Innovaccer, a San Francisco-headquartered company that says it activates the flow of healthcare data, empowering providers and payers to deliver “intelligent and connected experiences that advance health outcomes.”
- Washington (JF Noridian): Virtix Health LLC, a Phoenix firm focused on clinical data acquisition, HEDIS (Healthcare Effectiveness Data and Information Set) quality reporting and risk adjustment coding for providers and health plans.
- Arizona (JF Noridian): Zyter Inc., a Rockville, Maryland, health technology company supporting 45 health plans and over 44 million covered lives, helping with utilization management and care integration.
WISeR will focus on over a dozen services Medicare says are often subject to fraud, including image-guided decompression of the spine, epidural steroid injections for pain management, and percutaneous vertebral augmentation. Medicare previously said such services are often prone to abuse, and it’s offering incentives to tech firms curb their utilization.
“Participants will earn shared savings by reducing unnecessary care and meeting performance targets,” ACR noted in its news update. “Providers and suppliers who do not submit prior authorization requests for included services claims will automatically be subject to medical review to confirm compliance with Medicare coverage, coding and payment criteria before payment.”
The American Hospital Association previously urged the Centers for Medicare and Medicaid Services to delay the model for at least six months to give providers more time to prepare. Meanwhile, the Society of Interventional Radiology recently announced its opposition, contending related care delays could potentially kill seniors.
The model excludes several clinical scenarios such as inpatient stays, emergency care or instances when prior authorization may pose “substantial risk to patients if significantly delayed.” Technology companies tasked with handling these expedited reviews must utilize the expertise of clinicians in reaching their decisions, the agency emphasized. Final claim-denial denials will rest in the hands of docs and “not machines.”
CMS will test the model over six years beginning in 2026. The agency said it chose the six states because they have adequate volume to measure the model’s impact, geographic diversity, and currently provide coverage for skin and tissue substitutes, among other factors.
Participants’ payments will be adjusted based on their performance against established measurements. This will include the ability to support “faster decision-making for providers and suppliers” while improving the prior authorization experience for both docs and their patients. Officials emphasized that WISeR will not change Medicare coverage nor payment criteria, with beneficiaries still free to seek care from their physician of choice.
Members of Congress also have voiced their opposition to WISeR, echoing concerns presented by physician groups. Multiple democratic members of the U.S. House on Nov. 11 introduced legislation to block the model from happening. Those sponsoring the bill include Reps. Rick Larsen, D-Wash., Suzan DelBene, D-Wash., Kim Schrier, MD, D-Wash, Greg Landsman, D-Ohio, Ami Bera, D-Calif., and Mark Pocan, D-Wis.
“As a doctor and former chief medical officer of Sacramento County, I’ve seen how harmful prior authorization can be when it delays or denies necessary care for patients,” Bera said in a statement Nov. 11. “The WISeR model takes that a step further by financially rewarding companies for denying care through so-called ‘averted expenditures.’ That creates a dangerous incentive to put profits ahead of patients’ health. These decisions should be made by doctors, not by algorithms designed to cut costs.”
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.