Medicare’s Fresh Prior Authorization Push: What It Means for Patients and Providers
Starting January 1, 2026, traditional Medicare began implementing the Wasteful and Inappropriate Service Reduction (WISeR) Model, a significant shift towards prior authorization for certain medical services. While prior authorization is common in Medicare Advantage plans, it’s historically been rare in traditional Medicare. This change, utilizing technologies like artificial intelligence, aims to curb unnecessary healthcare spending, but raises concerns about potential delays in care and administrative burdens.
A Growing Burden: Prior Authorization in Healthcare
The rollout of WISeR comes at a time when a substantial majority – roughly seven in ten – U.S. Adults with health insurance find prior authorization burdensome. More than a third consider it their single biggest hurdle to accessing healthcare, exceeding even cost concerns. This frustration exists even as insurers voluntarily pledged to streamline the process in July 2025, a move coinciding with the announcement of the WISeR model.
What Services Are Affected?
The WISeR model initially focuses on a select group of services in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington. These include skin substitutes, orthopedic pain management services (like epidural steroid injections and cervical fusion), electrical nerve stimulator implants, incontinence control devices, and services related to the diagnosis and treatment of impotence. However, CMS has delayed the inclusion of deep brain stimulation and percutaneous image-guided lumbar decompression for spinal stenosis, representing less than 1% of the spending on the initially selected services.
The Numbers: Spending and Utilization Trends
In 2024, WISeR services accounted for 5.3% ($12.3 billion) of all Part B spending in traditional Medicare, a significant increase from 1.1% ($2.4 billion) in 2019. A striking 83% of this spending ($10.3 billion) was attributed to skin substitutes. Spending on skin substitutes has exploded, increasing over 20 times between 2019 and 2024, driven largely by a dramatic 820% increase in the average price per service.
Nearly 1.1 million traditional Medicare beneficiaries received at least one WISeR service in 2024. The vast majority (86%) received orthopedic pain management services, while only 9.3% received skin substitutes. Of those utilizing these services, roughly 20% were located in the six WISeR model states.
Price vs. Utilization: The Key Driver
The analysis reveals that the surge in spending isn’t primarily due to increased use of these services, but rather a steep rise in their price. This is particularly true for skin substitutes. Interestingly, CMS has simultaneously implemented nationwide changes to payment policy for skin substitutes, aiming to reduce Medicare spending on these products by nearly 90% in 2026. This change is expected to have a greater impact than the prior authorization requirements within the WISeR model itself.
State-by-State Variations
Per capita spending on WISeR services varied considerably among the six model states, ranging from $202 in Ohio to $748 in Oklahoma. Much of this variation stemmed from differences in spending on skin substitutes, influenced by both utilization and price per service.
Concerns and Opposition
The WISeR model has faced opposition from physician groups and members of Congress, who express concerns about increased administrative burdens and potential barriers to patient access. An amendment to prohibit spending on the model was approved by the House Appropriations Committee in September 2025, but ultimately wasn’t included in the final Consolidated Appropriations Act of 2026.
The Role of Artificial Intelligence and Potential for Expansion
CMS intends to use artificial intelligence and similar technologies to review the appropriateness of services. Health technology companies administering the prior authorization process will be eligible to share in savings generated from denied services. However, CMS has stated that vendors will be required to seek a second opinion from a human clinician before denying requests, and will be audited for compliance with Medicare coverage criteria.
While the initial scope is limited, CMS has indicated the possibility of expanding the WISeR model to include additional services and states in the future, potentially increasing its reach and impact.
Looking Ahead: Key Questions Remain
Several critical questions remain regarding the WISeR model’s long-term effects. Will it effectively reduce wasteful spending? Can safeguards protect patients from delays and denials? How will providers adapt to the new requirements? And how will CMS evaluate the model’s success and determine future expansion?
FAQ
Q: What is the WISeR model?
A: It’s a new Medicare program that requires prior authorization for certain medical services in six states, using technology to review their appropriateness.
Q: Which states are involved?
A: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington.
Q: What services require prior authorization?
A: Skin substitutes, orthopedic pain management services, electrical nerve stimulator implants, incontinence control devices, and services related to impotence.
Q: Will this affect all Medicare beneficiaries?
A: Initially, only those in the six model states receiving the specified services. However, the model could expand in the future.
Q: What is driving the increase in healthcare costs?
A: The analysis shows that the increase in costs is largely driven by the price per service, particularly for skin substitutes.
Did you grasp? The price per service for skin substitutes increased by 820% between 2019 and 2024.
Pro Tip: Stay informed about changes to Medicare policies by regularly visiting the CMS website.
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