Medicare's Implementation of Prior Authorization Trial Program in its Original Services
The Centers for Medicare & Medicaid Services (CMS) has announced the launch of the WISeR (Waste, Inappropriate Payments Identification, Review, and Containment) Model, a six-year pilot program starting January 1, 2026. The initiative is designed to curb fraud, waste, and abuse in Original Medicare by implementing prior authorization and pre-payment medical review for 17 services deemed vulnerable.
The WISeR Model will be deployed in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. Providers in these states should review WISeR guidance from CMS and update their billing practices in preparation for the changes.
CMS has partnered with technology companies to implement the WISeR Model, using enhanced tools like artificial intelligence and machine learning. The tech companies will be compensated based on their ability to help lower spending and avoid inappropriate utilization. Clinicians with expertise will be employed by these companies for medical reviews.
The decisions on denial or approval will remain clinical, but providers may face new paperwork and delays in administering care due to the WISeR Model. The Model targets services known for overuse or limited clinical benefit, including skin and tissue substitutes, electrical nerve stimulator implants, knee arthroscopy for osteoarthritis, cervical fusion, epidural steroid injections, and deep brain stimulation for Parkinson's disease.
CMS aims to reduce unnecessary or low-value care, protect federal taxpayer dollars, ensure Medicare beneficiaries receive medically appropriate and safe services, and encourage transparent medical necessity reviews using AI integrated processes.
If successful, the WISeR Model may be extended to new states or additional services. However, medical groups and physician advocates have expressed concerns that the WISeR Model may increase administrative burdens for providers.
Patients should consult their providers about whether services they expect to receive are on the WISeR list and clarify the prior authorization process. If you have Original Medicare plus a Medicare Supplement plan (Medigap), you may encounter prior authorization reviews for certain services.
It is important to note that patients can contact an organization's Medicare Advisory Service for help with Medicare plans or any questions they may have about Medicare. The WISeR Model may delay care for some patients due to the prior authorization process, but all final determinations to deny a claim will be made by licensed human clinicians.
Providers can choose to submit a prior authorization request before performing a service or face a post-service medical review. CMS may introduce a 'gold carding' process to exempt providers with high prior authorization approval rates from future reviews, reducing administrative burdens.
The WISeR Model also considers review volume, processing timeliness, and determination clarity in payment calculations for the partnered tech companies. The Model may challenge provider autonomy in determining what is clinically appropriate for their patients, but its ultimate goal is to ensure that Medicare beneficiaries receive high-quality, cost-effective care.
Lastly, Medicare Advantage plans will continue to make coverage decisions for their enrollees, but may have new or updated prior authorization requirements in 2026. As the WISeR Model progresses, it is crucial for both providers and patients to stay informed and engaged in the process to ensure the best possible outcomes for all involved.
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