The WISeR Model tests the use of enhanced technology to decrease certain wasteful (low-value) services shown to have little to no clinical, evidence-based benefit. Technology companies participating in the model will help streamline the review of medical necessity for select items and services earlier in the claims process to: 1) reduce inappropriate utilization, 2) lower spending in Original Medicare, 3) expedite decision making and(4) ease provider administrative burden.
Background
Original Medicare’s fee-for-service payment structure pays health care providers for the volume of services provided, which may incentivize medically unnecessary treatments, diagnostic tests or other care. The WISeR Model focuses on a specific subset of items and services that may have little to no clinical benefit for certain patients and that historically have had a higher risk of waste, fraud and abuse. This includes skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy for knee osteoarthritis. Such items and services, when delivered inappropriately, may result in harm to people with Medicare: financial (out-of-pocket costs), physical (i.e., complications like the risk of infection), or psychological (i.e., anxiety over tests and procedures).
Goals
The WISeR Model aims to:
- Focus health care spending on items and services that will improve patient well-being;
- Apply commercial payer processes that may be faster, easier and more accurate;
- Increase transparency on existing Medicare coverage policy; and
- De-incentivize and reduce use of medically unnecessary care.
Innovation
WISeR is the first Innovation Center model in which technology innovators will be the only model participants, and it is also the first model that incentivizes the use of cutting-edge tools to ensure that payment complies with Medicare documentation, coverage, payment and coding rules.
Through this approach, WISeR can provide a roadmap for incorporating more private sector innovations into CMS operations.
Design
WISeR does not change Medicare coverage or payment policy.
Participants will apply their technology in an assigned state to assess coverage determinations for a select set of items and services that: 1) may pose concerns related to patient safety if delivered inappropriately; 2) have existing publicly available coverage criteria; and 3) may involve prior reports of fraud, waste and abuse.
Examples of selected items and services include:
- skin and tissue substitutes;
- implantation of electrical nerve stimulators; and
- knee arthroscopy for knee osteoarthritis.
The model excludes inpatient-only services, emergency services, and services that would pose a substantial risk to patients if delayed.
All recommendations for non-payment will be determined by appropriately licensed clinicians who will apply standardized, transparent and evidence-based procedures to their review.
Health care coverage for people with Medicare will not change, and they retain the freedom to seek care from their Original Medicare provider or supplier of choice.
Payment to providers and suppliers for covered items and services will not change under the model.
WISeR does not apply to people with Medicare Advantage and will have no impact on them.
