{"id":15664,"date":"2025-11-13T06:35:07","date_gmt":"2025-11-13T06:35:07","guid":{"rendered":"https:\/\/distilinfo.com\/healthplan\/?p=15664"},"modified":"2025-11-13T06:35:07","modified_gmt":"2025-11-13T06:35:07","slug":"medicare-prior-authorization-changes-2","status":"publish","type":"post","link":"https:\/\/distilinfo.com\/healthplan\/medicare-prior-authorization-changes-2\/","title":{"rendered":"Medicare Prior Authorization Changes Under WISeR Program"},"content":{"rendered":"

Overview of the WISeR Initiative<\/strong><\/h2>\n

The Centers for Medicare & Medicaid Services (CMS)<\/a> is implementing a significant policy shift through the Wasteful and Inappropriate Service Reduction (WISeR) initiative, which introduces prior authorization requirements to traditional Medicare for the first time. This groundbreaking program, set to launch January 1, 2026, represents a fundamental change in how Medicare beneficiaries access certain medical services. The initiative will run through December 31, 2031, affecting healthcare providers and patients across six pilot states.<\/p>\n

The program aims to reduce unnecessary medical procedures while controlling healthcare costs in traditional fee-for-service Medicare. However, the initiative has sparked considerable debate among lawmakers, healthcare organizations, and medical professionals about its potential impact on patient care access and administrative burden on providers.<\/p>\n

Participating Vendors and Pilot States<\/strong><\/h2>\n

CMS has selected six specialized healthcare technology vendors to facilitate the prior authorization process during the pilot phase. The approved vendors include Cohere Health, Genzeon Corp., Humata Health, Innovaccer, Virtix Health, and Zyter<\/strong>. These companies will provide the technological infrastructure and administrative support necessary to process authorization requests efficiently.<\/p>\n

The pilot program will initially operate in six strategically selected states: Arizona, Washington, New Jersey, Texas, Ohio, and Oklahoma<\/strong>. Healthcare providers practicing in these states will need to navigate the new prior authorization requirements for specific Medicare services. This geographic limitation allows CMS to evaluate the program’s effectiveness before potential nationwide expansion.<\/p>\n

Political Opposition and Legislative Challenges<\/strong><\/h2>\n

The WISeR initiative faces substantial political resistance, particularly from House Democrats who have raised concerns about its implementation. In November, six Democratic representatives introduced legislation specifically designed to shut down the pilot program before it begins. Their opposition centers on concerns about access to care and increased administrative burdens on healthcare providers.<\/p>\n

The House Appropriations Committee took decisive action by advancing a 2026 spending bill that includes an amendment blocking funding for the pilot program. Representative Lois Frankel (D-Fla.), who introduced this amendment during a September 9 meeting, expressed strong opposition, stating, “Let’s not bring this nightmare to Medicare, the one program that seniors still count on for guaranteed straightforward care.” Lawmakers have also introduced a resolution opposing WISeR, particularly scrutinizing its use of artificial intelligence to expedite prior authorization decisions.<\/p>\n

Healthcare Industry Response and Concerns<\/strong><\/h2>\n

The American Hospital Association (AHA) has been particularly vocal in its criticism of the program’s rushed timeline. In an October 23 letter to CMS, the organization outlined several critical recommendations, including delaying the program by at least six months<\/strong> to allow adequate preparation time. The AHA emphasized the need for establishing clear guardrails for AI use in healthcare decision-making and revising the vendor payment methodology to ensure fair compensation structures.<\/p>\n

Healthcare organizations worry that adding prior authorization to traditional Medicare could replicate the administrative challenges currently plaguing Medicare Advantage plans. An American Medical Association survey revealed that physicians and their staff already spend approximately 12 hours per week<\/strong> managing prior authorization paperwork, raising concerns about increased administrative burden.<\/p>\n

Implementation Timeline and Affected Services<\/strong><\/h2>\n

CMS released a comprehensive provider and supplier operational guide on October 10 to help healthcare professionals prepare for the transition. The document outlines various procedural steps for providers adapting to the new authorization process. Notably, CMS announced it would delay including deep brain stimulation<\/strong> in the initial rollout, planning to reevaluate its inclusion later.<\/p>\n

The program specifically targets several high-cost medical procedures, including deep brain stimulation for Parkinson’s disease, epidural steroid injections for pain management, and cervical fusion surgeries. These services were selected based on cost considerations and utilization patterns in traditional Medicare.<\/p>\n

Provider Requirements and Operational Changes<\/strong><\/h2>\n

Healthcare providers in pilot states must implement significant operational changes to comply with WISeR requirements. They’ll need to submit authorization requests before performing covered procedures, potentially delaying patient care. The operational guide provides detailed instructions for navigating the authorization process, including documentation requirements and appeal procedures.<\/p>\n

Impact on Medical Practices and Workflow<\/strong><\/h2>\n

Earlier this year, CMS Administrator Mehmet Oz, MD, supported insurers’ efforts to simplify existing prior authorization processes, acknowledging the administrative challenges facing medical practices. However, the WISeR initiative introduces these same challenges to traditional Medicare, which previously operated without such requirements. Medical practices must now allocate additional staff time and resources to manage authorization requests, potentially affecting their ability to serve patients efficiently.<\/p>\n

The coming months will be critical as stakeholders continue debating the program’s merits while providers prepare for implementation in the six pilot states.<\/p>\n

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