What You Should Know:
– Humata Health, a provider of AI-powered prior authorization technology, has been selected by the Centers for Medicare & Medicaid Services (CMS) as a key partner for its new initiative: the Wasteful and Inappropriate Service Reduction (WISeR) model.
– CMS, the single largest payer for healthcare in the U.S., has chosen Humata Health to deploy its proprietary technology in a program that directly addresses the staggering variability of care and significant low-value services provided to Medicare beneficiaries each year. The WISeR model is a defining opportunity to use technology to bring physicians and payers closer together, with the patient’s best interest as the primary focus.
Targeting Waste and Accelerating Approvals in Oklahoma
The WISeR model is set to launch in January 2026 across six states: Arizona, Ohio, Oklahoma, New Jersey, Texas, and Washington. Humata Health will serve as the primary technology partner for Oklahoma, processing all WISeR prior authorization requests from providers across the state.
The initiative will initially focus on a specific list of 17 items and services that have historically shown high rates of fraud, waste, abuse, and potential for patient harm.
The primary function of Humata’s technology is to accelerate approvals. By intelligently matching clinical documentation to Medicare policy criteria, the system delivers a rapid, automated “yes” decision for appropriate services—often in days, not weeks. Crucially, the AI can only approve requests; any complex cases that are not an instant “yes” are automatically escalated to a human clinician for review, ensuring no denials are made without a clinical expert.
Combating Low-Value Care and Skyrocketing Costs
The need for a program like WISeR is underscored by the prevalence of low-value care in the U.S. Each year, up to 40% of Medicare beneficiaries—approximately 27 million seniors—receive care that provides little-to-no clinical benefit and may even cause harm.
- Low-Value Examples: The targeted list of services includes procedures like knee arthroscopy for seniors, which studies have shown offers little to no benefit for people over 65.
- Addressing Fraud and Waste: The model also targets items like skin substitutes, a category where Medicare spending exploded to $10 billion in 2024—a 640% increase in just two years—despite limited clinical evidence and documented fraud.
As Humata Health Founder and CEO, Jeremy Friese, MD, stated, “Humata’s core mission is to ensure that every patient receives the right care as quickly as possible. We feel a profound responsibility to prove that this can be done the right way.”
