In a pilot program set to begin in 2026, CMS will test new prior authorization requirements for 17 services in six states.
Prior authorization (PA) has been a relatively small part of the Traditional Medicare program, with Medicare Advantage plans processing more than 100 times as many requests in 2023. However, CMS is launching a new pilot program. The Wasteful and Inappropriate Service Reduction (WISeR) Model, to test increased PA requirements for 17 services considered vulnerable to waste and abuse.
The pilot, scheduled to run from 2026 to 2031, represents a significant shift for CMS, which will partner with technology companies rather than traditional Medicare Administrative Contractors. For providers in the six pilot states, it will introduce a new workflow and a choice between submitting a pre-service prior authorization request or undergoing a post-service pre-payment review for the targeted services.
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Luke Gale is the revenue cycle editor for HealthLeaders.
KEY TAKEAWAYS
CMS is launching a pilot from 2026 to 2031 to test prior authorization requirements for 17 services in six states.
Providers in the pilot states will have two options: submit a prior authorization request before the service or undergo a pre-payment medical review after.
The model represents a significant shift, with CMS partnering directly with technology companies to manage utilization in Traditional Medicare.