Plans to test prior authorization in traditional Medicare are deeply troubling [View all]

This is an opinion piece, but I think it is important to present here:

"For both patients and clinicians, one of the advantages of traditional Medicare is that it almost entirely lacks the onerous preauthorization reviews that plague the program’s privately administered Medicare Advantage option.

But under a new demonstration program recently announced by the Centers for Medicare and Medicaid Services, that’s about to change. Preauthorization is about to enter the lives of seniors who have chosen traditional Medicare over Medicare Advantage (MA).

CMS is calling this new model “WISeR”: Wasteful and Inappropriate Service Reduction.

We have seen this movie before.

The goal, according to the Innovation Center at CMS, is to test a new model to target “wasteful, inappropriate services in Original Medicare.” Testing new models of payment and rolling out demonstration programs like WISeR is the stock and trade of the Innovation Center, created under the Affordable Care Act. But this foray into preauthorization is hardly innovative. MA plans have been playing these games for years.

Briefly, under the WISeR model, CMS will contract with organizations to approve or deny a clinician’s request to provide a service (in order to be able to receive payment for it). The model will require this prior authorization for a list of outpatient procedures that meet one or more of several criteria, such as a history of overuse. The contractors are supposed to use artificial intelligence as well as other tools to make prompt decisions."

https://www.statnews.com/2025/07/25/medicare-advantage-prior-authorization-cms-innovation-center-wiser-project/