Certain Medicare beneficiaries are slated to encounter a novel “prior authorization” requirement as the Centers for Medicare & Medicaid Services (CMS) tests its extensively debated “” model.
This initiative, which CMS unveiled in June, mandates that Original Medicare recipients secure pre-approval prior to accessing specific medical services. The pilot program is scheduled to operate in only six states.
Medicare serves as health insurance for individuals 65 years of age and above. Younger individuals may also qualify for this coverage if they have a disability, End-Stage Renal Disease (ESRD), or ALS. Nearly Americans rely on this government-funded program for their healthcare insurance requirements. Consequently, any modifications to the program are expected to have widespread repercussions.
In early August, a group of Democrat legislators sent a letter to CMS Administrator Mehmet Oz—also known as Dr. Oz—expressing worries that the suggested prior authorization procedures could “likely restrict beneficiaries’ access to care” and “foster perverse incentives that prioritize profit above patients.”
With increasing interest, here is essential information regarding the Medicare pilot program.
What does the Medicare prior approval pilot entail?
According to the CMS, the WISeR model,, is designed to “evaluate methods for delivering an enhanced and accelerated prior authorization process compared to Original Medicare’s current procedures” with the goal of “assisting patients and providers in preventing unnecessary or unsuitable care” and simultaneously “protecting federal taxpayer funds.”
The Medicare Payment Advisory Commission reported that Medicare expended as much as $5.8 billion in 2022 on “unneeded or unsuitable services offering minimal to no clinical advantage.”
The WISeR model is purportedly designed to address this issue, engaging private firms to assess if AI can manage the prior authorization procedure that ascertains an Original Medicare recipient’s—also referred to as Traditional Medicare—eligibility for health service funding. This model will specifically focus on services that CMS deems “especially susceptible to fraud, waste, and abuse.”
The CMS notice stated, “These items and services encompass, though are not limited to, skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy for knee osteoarthritis.”
CMS has confirmed its intent to exclude several categories of services from the WISeR pilot, including “inpatient-only services, emergency services, and services that would present a significant risk to patients if considerably postponed.”
Dr. Oz stated, “CMS is dedicated to eradicating fraud, waste, and abuse, and the WISeR Model will assist in eliminating inefficiency within Original Medicare.”
This model is not expected to affect individuals enrolled in Medicare Advantage, which offers additional benefits and coverage beyond the standard Original Medicare program, and already incorporates a prior authorization process.
Private entities participating in this program will receive compensation determined by their “capacity to diminish unnecessary or uncovered services,” which largely equates to the amount of money they can conserve in healthcare expenditures.
When is the Medicare pilot program scheduled to commence?
The WISeR model is slated for launch on January 1, 2026, and is projected to “operate for six performance years” to assess its efficacy, concluding on December 21, 2031.
Which states are anticipated to be affected?
Per the CMS, the WISeR pilot will be implemented in six states across the United States.
Washington, New Jersey, Oklahoma, Ohio, Texas, and Arizona are expected to experience its effects.
Firms chosen for the program, tasked with conducting AI-powered prior authorization, will be allocated distinct geographical areas for their operations.
What criticisms have been directed at the new Medicare model?
Democrat legislators expressed their concerns to Dr. Oz on August 27, articulating fears that the forthcoming prior approval procedures might lead to harmful delays adversely affecting patients.
The 17 Democrat signatories stated, “WISeR is likely to restrict beneficiaries’ access to care, escalate the burden on our already strained healthcare workforce, and foster perverse incentives that prioritize profit over patients,” drawing parallels to how prior authorization has affected clients filing claims under Medicare Advantage.
The legislators contended that “numerous patients opt for Traditional Medicare due to their understanding that their care decisions will be made by their doctors, rather than by insurance companies.”
The letter, endorsed by figures such as California Rep. and Illinois Rep. , underscored worries regarding the profit motives linked to prior authorization, a process also employed by private insurance firms that commonly engage external entities to perform such evaluations.
In their address to Dr. Oz, Democrats critiqued the Trump Administration, emphasizing that government officials had previously acknowledged the problems associated with prior authorization.
On June 23, Republican lawmakers, alongside Health and Human Services Secretary Robert Kennedy Jr., aimed to “rectify the flawed prior authorization system.”
North Carolina Congressman Greg Murphy, drawing upon his decades of experience as a physician, remarked: “I observed the absurd and perpetually growing impediments created by insurance companies, leading to delayed or denied patient care.”
Referring to this concession from the Republican party, the Democrats penned: “Yet, barely a week following these declarations, CMS presented a new proposition to escalate the application of prior authorization in a form of health coverage that had rarely employed this strategy previously, substituting medical expertise with an algorithm intended to maximize care denials for greater profits.”
TIME has contacted CMS for its response concerning these issues.