The Centers for Medicare and Medicaid Services (CMS) recently announced Texas as one of six states selected for participation in the WISeR (Wasteful and Inappropriate Service Reduction) Model.
The six-year voluntary model, which is scheduled to run from Jan. 1, 2026, through Dec. 31, 2031, is designed to modernize Medicare’s claims review process by leveraging enhanced technologies, including artificial intelligence and machine learning. Through a partnership with private-sector technology firms, CMS aims to reduce the delivery of low-value or medically unnecessary services, improve outcomes and streamline administrative burdens.
In Texas, Cohere Health Inc., has been named as a WISeR Model participant under the Novitas MAC jurisdiction. The company will be responsible for reviewing a specific set of Medicare services identified as vulnerable to fraud, waste or abuse, such as skin and tissue substitutes, electrical nerve stimulator implants and knee arthroscopy procedures for osteoarthritis.
These reviews will be conducted using advanced technology platforms supported by clinical staff. According to CMS, recommendations for non-payment will always be made by licensed clinicians following standardized, evidence-based criteria.
The model does not alter Medicare coverage or payment policy but introduces a new layer of pre- or post-service review for selected services. Health-care providers and suppliers in Texas who serve Original Medicare beneficiaries will have the option to submit prior authorization requests through model participants. Those who do not may be subject to post-service reviews to ensure compliance with Medicare rules.
One of the model’s key features is a performance-based incentive structure. Participating technology firms like Cohere Health will receive a percentage of the savings resulting from reductions in unnecessary services. That percentage will be adjusted based on provider experience and process-related metrics.
The WISeR Model is the first CMS initiative of its kind in which only technology firms, not traditional health-care organizations, are eligible to participate. It also marks a new approach by CMS to integrate private-sector innovation directly into its operations, with a stated goal of developing scalable strategies for future federal health oversight.
For Texas-based vendors, the model presents potential opportunities and considerations. Organizations providing digital health tools, clinical decision support or claims automation solutions may find new pathways to engage with Medicare-affiliated providers adjusting to the WISeR framework. Additionally, the program could drive demand for analytics services, audit-readiness tools and other AI-driven platforms that align with the model’s compliance requirements.
Texas to Participate in New Tech-Driven Medicare Review Program
What to Know:
- Texas is a pilot state in CMS’ new WISeR Model, which uses AI and clinical review to reduce wasteful Medicare spending.
- Cohere Health will operate in Texas, reviewing select Medicare services for medical necessity under the model.
- Providers face new review options, including pre-authorization through WISeR participants or post-service audits, starting in 2026.
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