healthcare AI platforms How a federal innovation model met production reality in 90 days.
A long-form report on the first 90 days of the CMS WISeR Model in New Jersey — how AI-assisted Medicare prior authorization came online, stabilized, and reached steady-state at federal SLA standards.
12,609
Prior authorization cases processed end-to-end in the first quarter.
100%
Compliance with the federal turnaround standard, sustained across the quarter.
<1 day
Turnaround for 90% of all standard cases — well inside the federal window.
85%
Of providers submitting via the WISeR portal — the fastest, most accurate channel.
A first-of-its-kind federal AI program, in production, on time.
In June 2025, CMS announced the Wasteful and Inappropriate Service Reduction (WISeR) Model — a six-year Innovation Center program (2026–2031) testing whether AI-assisted prior authorization could reduce inappropriate Medicare Fee-for-Service spending without restricting access to medically necessary care. Genzeon Platforms was selected as the WISeR Participant for New Jersey, working with Novitas Solutions in MAC JL. Production go-live was January 1, 2026. By the close of Q1 2026, the program had processed 12,609 prior authorization cases at full federal SLA, with sustained 100% three-day turnaround and a steadily improving operational envelope. This is the story of how it came online — what worked, what required adjustment, and where the program goes next.
CMS WISeR
2026–2031 · Medicare Fee-for-Service prior authorization · AI-assisted, human-decided. CMS →
13 categories
Elective procedures with documented over-utilization and clear coverage criteria — spinal injections, skin substitutes, sacral nerve devices, and more.
Jan 1, 2026
First production day, on the date CMS published — no soft launch, no extended pilot.
Healthcare waste, friction, and why the status quo isn't working for anyone.
Prior authorization, as it operates today, is failing every stakeholder it touches. Patients wait. Providers spend hours that should be spent on care. Payers carry administrative cost without recovering value. And Medicare carries hundreds of billions in annual spend on services that, on retrospective review, often did not need to be delivered. WISeR exists because the conventional answer — review after the fact, dispute after payment — is the wrong shape for the problem.
of physicians say prior authorization delays necessary care.
PA-driven delays are not edge cases — they are the modal experience reported by U.S. physicians.
AMA Prior Authorization Physician Survey, 2023 (n=1,000+)
say PA leads patients to abandon needed treatment.
Friction in the authorization process translates directly to clinical drop-off. The cost of a delay is not just paperwork — it is care that doesn't happen.
AMA Prior Authorization Physician Survey, 2023
in estimated annual U.S. healthcare waste.
Inappropriate utilization, administrative complexity, and fraud and abuse compound at population scale. Medicare carries a meaningful share.
JAMA Network Open, 2019
per practice, per week spent on prior authorization administration.
A full-time-equivalent workload absorbed by clinical practices to navigate authorization. Time pulled from the bedside, the call list, the chart.
MGMA Administrative Burden Report, 2024
Lose time and revenue.
Practices spend forty-plus hours a week on PA tasks. Smaller clinics lack the administrative infrastructure to appeal denials, leading to foregone revenue and clinician burnout. Post-acute facilities — skilled nursing, home health, ambulatory surgery — face the highest denial rates of any care setting and the fewest resources to dispute them.
Wait — and some can't afford to.
Average wait times of two to three weeks for elective procedures create cascading downstream effects. For Medicare beneficiaries — often older and more clinically fragile — delays can mean readmissions, complications, and worse outcomes. The cost of waiting is borne unevenly.
Carries hidden costs.
Medicare spends hundreds of billions annually on services with a meaningful share deemed potentially inappropriate on post-payment review. The current model — review after the fact, dispute after payment — is expensive and slow for everyone. WISeR shifts the review forward: settle the clinical necessity question before the service is rendered, not after the bill arrives.
A six-year CMS innovation model. New Jersey first.
CMS launched the WISeR Model on January 1, 2026 — a six-year Innovation Center program testing whether AI-assisted clinical review, applied before payment, can reduce inappropriate services while protecting access to medically necessary care. Six states. Six commercial platform partners. One coordinated federal experiment.
Why WISeR exists.
CMS estimates hundreds of billions in annual Medicare waste. WISeR tests whether AI-assisted clinical review — applied before payment — can reduce inappropriate services while protecting access to medically necessary care and promoting payment integrity. It is the federal government's first commercial-AI-assisted prior authorization model, and the regulatory pattern most likely to inform broader Medicare and Medicare Advantage policy.
How the model runs.
WISeR operates in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. Each state has a single designated WISeR Participant — a technology company responsible for managing prior authorization and pre-payment review for select Medicare services in partnership with the state's Medicare Administrative Contractor. New Jersey's partner is Genzeon.
What gets reviewed.
WISeR covers thirteen categories of elective procedures with a history of overuse — including epidural steroid injections, percutaneous vertebral procedures, sacral nerve stimulation devices, skin substitutes, and cervical fusion. Each category was selected for clear coverage criteria, sufficient volume, and known fraud-and-waste exposure. CMS scope details →
Six-year model period.
The program runs through 2031. Performance years align with calendar years. CMS publishes operational guidance through the WISeR Provider/Supplier Operational Guide and the Innovation Center Model Overview. Genzeon participates as the model technology provider in MAC JL (New Jersey, Novitas Solutions).
Why this matters beyond Medicare FFS: The architectural standards CMS validated under WISeR — clinician-in-the-loop on every adverse determination, per-criterion citation chains, no auto-deny — are the same standards now appearing in CMS-0057-F (the January 2027 FHIR PA mandate) and emerging state AI laws. The New Jersey deployment is, in effect, a regulatory dress rehearsal for what will become the default architecture for AI-assisted PA across the U.S. healthcare system — for payers, providers, and government programs alike.
How WISeR works in New Jersey.
Providers have two routes. Both are reviewed with AI-assisted clinical decision support, and both preserve every standard Medicare appeal right. No clinical determination — affirmative or otherwise — is made by AI alone. Every non-affirmation routes to a licensed clinician.
Submission & intake
Online portal (the preferred channel — 85% adoption), fax, or esMD via the MAC. Clinical documentation supporting medical necessity is submitted before the service is performed.
AI-assisted clinical review
Each case is evaluated against Medicare NCD/LCD criteria. The AI agent surfaces the criteria-by-criteria evidence picture; a licensed clinician reviews every potential non-affirmation. Three-day standard window. Two-day expedited.
Provisional affirmation or non-affirmation
Affirmations include a Unique Tracking Number (UTN) required on the subsequent claim. Non-affirmations include detailed rationale and resubmission guidance. Providers may resubmit unlimited times and may request peer-to-peer clinical review.
Service rendered, claim submitted
Service is delivered. Claim is submitted with the UTN. All standard Medicare appeal rights are fully preserved regardless of route.
For providers who choose to submit a claim without prior PA.
Providers may submit a claim without a prior authorization. Genzeon then conducts pre-payment review before the MAC pays the claim. The MAC approves or suspends payment based on the review. Non-affirmations do not prevent care from being delivered. Providers retain all standard Medicare appeal rights regardless of which route they choose. Across Q1 2026, 309 cases came through this pre-payment review path.
The architectural commitment under WISeR is explicit: no automatic denials. Every adverse determination is reviewed by a licensed clinician with relevant specialty expertise. This is not a policy preference — it is built into the system at the architectural level.
From launch to stability — the first 90 days.
Building a first-of-its-kind federal AI prior authorization program in real time means the launch is the easy part. What comes after — the operational stabilization, the alignment work between coordinated parties, the iterative process maturity — is where the program's actual shape gets decided. Three phases describe how the New Jersey deployment moved from go-live to steady-state.
Standing up operations.
- Production go-live on January 1, 2026 — the date CMS published, no soft launch.
- Provider portal access established; MAC coordination protocols agreed.
- Electronic submission workflows stood up across all thirteen service categories.
- Early edge cases identified and escalated for resolution under live operations.
Resolving early friction.
- Early data-formatting alignment work between coordinated parties to ensure clean handoffs at every system boundary.
- Automated batch processing implemented to handle peak submission volume without degradation.
- Daily operational monitoring with weekly coordination cadence established across all parties.
- Submissions consistently processed within the federal three-day turnaround requirement throughout the period.
Continuous improvement.
- Continuous process improvement across submission, review, and decision-issuance pipelines.
- Provider education materials reduced repeat submission errors and accelerated portal adoption.
- Performance metrics trending consistently positive across all operational dimensions.
- By April, 90% of all standard cases decisioned within one day — well below the federal three-day window.
The model was the easy part. The hardest production work in a federal AI program is not AI behavior — it is integration validation, request-pattern variation across regions and provider types within a single MAC, and the volume of administratively correctable submissions that surface only at production scale. Pre-production evaluation predicted clinical-review behavior well. Pre-production evaluation could not have predicted the full distribution of submission edge cases. The work that mattered most in the first 90 days was operational alignment between coordinated parties — not model tuning.
The numbers — actual prior authorization and pre-payment review volumes.
Production performance for the first quarter under the WISeR Model in New Jersey, January through March 2026. End-to-end measurement: provider intake through clinical decision through letter delivery.
Total prior authorization cases processed end-to-end across the thirteen WISeR service categories.
77% of Q1 PA volume — the dominant service category by submission count, primarily an outpatient pain-management procedure.
Cases where providers chose to submit claims without prior authorization, then routed through pre-payment review before MAC payment. Roughly 78% of these were also ESI.
Sustained across the quarter — not a one-week peak. Meeting the federal SLA standard at full operational volume.
Procedures performed in ASC, SNF, home health, and outpatient facilities. The setting where retroactive denials hurt most.
The WISeR program is not designed to maximize denials — it is designed to ensure appropriate care is approved efficiently. Categories with mature rule packs show high affirmation rates for well-documented submissions.
91% of New Jersey WISeR PA volume runs through procedures performed in post-acute settings.
Where the work happens.
Spinal injections, sacral nerve devices, skin substitutes, cervical fusion — the majority of WISeR's thirteen service categories are delivered in ASCs, SNFs, home health, and outpatient facilities. The program was designed around this setting.
Why the timing matters.
For post-acute care, a retroactive denial doesn't just mean paperwork. It can mean financial hardship, care disruption, or readmission. WISeR settles the clinical necessity question before the patient arrives — not after the bill is sent.
Providers are submitting.
Epidural Steroid Injections alone — primarily an outpatient pain-management procedure — accounted for 9,718 of 12,609 total NJ WISeR PA requests in Q1 2026. New Jersey providers are submitting and adapting to the system with minimal disruption to their workflows.
May 2026 operations — stable, responsive, and improving.
Three operational dimensions describe the program at steady-state: turnaround speed, affirmation behavior, and provider channel adoption. All three are trending in the direction the program was designed to produce.
Turnaround performance.
90% of all cases decisioned within one day since April 2026. 100% of cases decisioned within the federal three-day window — sustained across the quarter, not a one-week peak.
Target: 95%+ standard cases decisioned in one day by Q3 2026.
Approving appropriate care.
The WISeR program is not designed to maximize denials — it is designed to ensure appropriate care is approved efficiently. Service categories with mature rule packs show high affirmation rates for well-documented submissions, validating the program's clinical-necessity model.
Provider channel preference.
The provider portal remains the quickest and most accurate form of PA submission. One-stop shop for pre-built coverage checks, decision support on submission, tracking of submitted PA and ADR requests, and analytics for facility administrators.
MedTech Breakthrough 2026
AI-Powered Healthcare Innovation Award. Recognized for HIP One and the CMS WISeR New Jersey deployment — agentic AI for prior authorization in production at federal scale.
Bronze Stevie® 2026
Bronze Stevie® American Business Awards 2026 — AI in Healthcare Achievement. Aether One™ recognized as the agentic platform delivering AI-assisted prior authorization live in CMS Medicare. The architecture is patent-protected. See the honest peer set →
WISeR New Jersey, where Genzeon is headed, and how we partner.
The program continues through 2031. The architecture validated under WISeR — clinician-in-the-loop, per-criterion citation, rule-grounded decisioning — is the same architecture that meets CMS-0057-F (the January 2027 FHIR PA mandate) and the broader regulatory window opening across U.S. healthcare. The roadmap below tracks the program forward and the platform forward in parallel.
WISeR NJ in full stride.
- All 13 service categories processing.
- Provider channels and operations fully staffed.
- Deeper MAC integration and pre-submission validation reducing UTN failures.
- Performance metrics reported to CMS quarterly.
Two major provider product launches.
- Prior Auth FHIR App listed on Epic App Orchard.
- Denial Prevention Agent — agentic AI that identifies and resolves denial risk before submission.
- Provider-facing tools informed directly by NJ WISeR learnings.
- Microsoft Dragon Copilot ambient AI integration live.
Compliance & expansion.
- WISeR program expansion (per CMS guidance).
- CMS-0057-F FHIR PA API compliance — all payer clients (Jan 2027 mandate).
- CMS-0062-P drug PA & NCPDP SCRIPT readiness (Oct 2027).
- Genzeon pharmacy benefit prior auth product launch.
Roadmap subject to CMS model guidance · Product availability may vary by deployment type
Authoritative sources.
Direct links to the CMS, MAC, and federal-system pages that anchor the WISeR deployment. The same canonical sources our rule packs and operations cite.
CMS WISeR Model
CMS Innovation Center program page. Model overview, participants, performance years, six-state geography. Open →
novitas-solutions.comNovitas Solutions · MAC JL
Operator partner portal. Provider-facing resources for MAC JL services across DE, DC, MD, NJ, and PA. Open →
cms.govWISeR FAQ
Frequently asked questions on coverage, participation, prior authorization workflow, and beneficiary impact. Open →
Go deeper.
Where to read more on the architecture, the deployment, and the regulatory program shaping this market.
WISeR Live Deployment
Production performance, architecture, and program references for the live CMS Medicare PA deployment in MAC JL.
See the deployment ProductHIP One — the platform underneath
The Health Intelligence Platform that runs the WISeR review pipeline. Live in CMS Medicare today.
Explore HIP One ArchitectureAether One™ — the substrate
The patent-protected agentic substrate beneath every Genzeon Platforms deployment. Decomposed agents, deterministic guardrails, audit-grade traceability.
Read the architecture For payersBuyer's view — health plans
The WISeR architecture applied to commercial PA, UM, and CMS-0057-F readiness for Medicare Advantage, Medicaid managed care, and commercial plans.
For payers For providersBuyer's view — health systems
The same engagement, denial-prevention, and ambient-documentation layer applied to provider workflows. Patient access, scheduling, post-discharge follow-through.
For providers For governmentFor government programs
Sovereign-deployment Medicare FFS prior authorization for federal, state, and program-integrity contexts. The WISeR architecture, available as a deployable platform.
Government view Field noteSix weeks inside live WISeR production
The companion engineering & policy note — what surprised the team, what required adjustment, what we'd do differently.
Read the field note IPPatent portfolio
The patents protecting the auto-affirmation system, agent orchestration, and audit-grade architecture validated by the live CMS WISeR deployment.
See the portfolio WhitepaperInside the Healthcare Brain
The architectural deep-dive. Triple-Tier Agentic Architecture, six substrate principles, governance invariants, patent foundation. ~5,800 words.
Read the whitepaper WhitepaperMedical PA Compliance Engineering
CMS-0057-F + CMS-0062-P implementation playbook for payers. FHIR PA APIs, decision timeframes, public reporting, no-auto-deny. ~5,400 words.
Read the whitepaper How to engageThree motions, three time-to-value paths
Buy the platform, buy the outcomes, or buy individual agents. Same architecture, different commitment shape.
How to engageA federal AI program in production. The architecture you can deploy.
If you are a payer, provider, or government program evaluating healthcare AI, the WISeR deployment is what production looks like at federal SLA standards. Let's talk about what that means for yours.