New Changes to Medicare and Private Prior Authorization Processes
Both the Centers for Medicare & Medicaid Services (CMS) and dozens of the nation’s largest insurance companies have revealed upcoming changes to their prior authorization processes. These changes aim to reduce the prevalence of fraud, waste and abuse in Medicare services and fix administrative inefficiencies for providers and patients, respectively.
Applying the WISeR Model to Medicare Prior Authorization
On June 27, 2025, the Centers for Medicare & Medicaid Services announced the Wasteful and Inappropriate Service Reduction Model (WISeR). This model is designed to expedite Medicare’s prior authorization processes and reduce health care waste through the implementation of artificial intelligence and advanced technologies. WISeR will be deployed in New Jersey, Ohio, Oklahoma, Arizona and Washington on Jan. 1, 2026, and will run for six years.
Through partnerships with AI-capable companies (WISeR-partners), CMS will use the model to test whether advanced technologies can reduce the length of current review processes and the amount of fraud, waste, and abuse for particular items and services.
WISeR will target items and services that:
- Pose patient safety concerns if they are inappropriately delivered
- Have publicly available coverage criteria
- Are shown to be vulnerable to fraud waste and abuse
CMS highlights skin and tissue substitutes, electrical nerve stimulators, and knee arthroscopy for knee osteoarthritis as examples of items and services that will undergo WISeR review.
WISeR-partners’ advanced technologies will analyze prior authorizations by requesting information and clinical documentation from providers to ensure that items and services are necessary and meet coverage requirements before being furnished. WISeR-partners will also use their advanced technologies to conduct pre-payment medical reviews for claims that were not submitted for prior authorization. Only clinicians working with the WISeR-partners, not the artificial intelligence and machine-learning technologies, will have the final authority to deny services. CMS provides detailed scenarios of WISeR-partner decision-making.
WISeR will not review inpatient-only services, emergency services, or services that cannot be substantially delayed without putting patients at risk. Also, WISeR will not change any Medicare coverage or payment policies and will not impact people enrolled under Medicare Advantage.
If WISeR is successful in expediting and refining Medicare prior authorization processes, CMS envisions that it could save billions of dollars in federal taxpayers’ money. WISeR-partners will receive incentive payments based on their ability to reduce “spending on medically unnecessary or non-covered services.”
Insurers’ Pledge to Simplify Prior Authorization
CMS’s announcement of the WISeR model arrived on the heels of a pledge made by dozens of the nation’s largest health insurers to voluntarily improve their prior authorization processes. Although prior authorization is designed to reduce unnecessary care, requests are often denied for necessary and covered care.
Participating insurers are committing to six initiatives that aim to:
- Reduce the number of services requiring prior authorization
- Standardize the prior authorization request process across the insurance market
- Provide quicker responses to prior authorization requests
The initiatives will be initiated on Jan. 1, 2026, and should be fully operational by Jan. 1, 2027.
These voluntary changes will impact those insured by commercial health plans, Medicare Advantage plans and Medicaid managed care plans.
Participating insurers, the Department of Health and Human Services, and the public all anticipate that these reforms will reduce administrative burdens for providers, accelerate care decisions and increase patients’ access to transparent and appropriate care.
