Prior authorization has come to traditional Medicare in six states

For most of its history, traditional Medicare paid first and asked questions later. Prior authorization was something practices associated with Medicare Advantage and commercial plans. The Wasteful and Inappropriate Service Reduction model, known as WISeR, changes that for a short list of services in six states.

The basics

• The model runs for six years, from January 1, 2026 through December 31, 2031.
• It applies in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington.
• It targets services CMS considers at higher risk of fraud, waste or low value. Examples CMS names include skin and tissue substitutes, electrical nerve stimulator implants and knee arthroscopy for knee osteoarthritis.
• Reviews are carried out by technology companies CMS selected as model participants.

Two ways through

For each covered service, providers in the model states choose a path. They can request prior authorization before the service, either directly with the model participant or through their Medicare Administrative Contractor. Or they can skip that step and have the claim go through a medical review after the service, before it is paid.

On paper the model is voluntary. In practice, skipping prior authorization means the claim is reviewed before payment, so the money waits either way. CMS says every recommendation not to pay is made by appropriately licensed clinicians. Analysts, including KFF, have noted that participants are paid in part from savings on services that are not paid for, which is why physician groups have asked for close oversight.

What this means for claims

The risk is the same one we see whenever a new authorization rule appears. A service is scheduled, performed and billed the way it was last year, and the claim ends up in review. For services on the WISeR list, the documentation that supports medical necessity needs to be in the chart before the request goes out.