Prior Auth Requirements for Traditional Medicare Ignite Debate

While the AHA has called on CMS to rethink its plan to add prior authorization requirements to traditional Medicare, some argue that the program is due for some utilization management.

CMS has sparked debate over its plan to add new prior authorization requirements into traditional Medicare.

Through the Widespread, Insufficient, and Enigmatic Service Revisions (WISeR) Model, which will last from 2026 through 2031, CMS is adding PA for 17 services in six states. 

The pilot program will test whether the utilization review tools common in Medicare Advantage (MA) can be used to reduce spending in the traditional Medicare program. CMS will partner with technology companies, rather than the usual Medicare Administrative Contractors, to test the ability of enhanced technologies, including AI, to streamline and expedite PA processes.

Hospitals Push Back Against "Unnecessary Obstacles"

Critics say the WISeR model represents yet another administrative burden. In an October 23 letter to CMS, the American Hospital Association applauded efforts to combat improper payments and fraud, but argued that the new PA requirements are flawed.

“We recognize that the WISeR model can be a useful tool to help ensure patient care is based on well-established evidence of efficacy and safety,” wrote Ashley Thompson, AHA Senior Vice President of Public Policy Analysis and Development. “However, prior authorization requirements, if not properly administered, can create dangerous delays in care and substantial provider administrative waste.”

The AHA called on CMS to significantly rethink some components to the pilot program.

• The AHA expressed concern over the plan to pay vendors 10% to 20% of the savings from care denials. The association argues this "creates a perverse incentive to deny care" and recommends CMS use a "flat fee compensation structure" instead.
• The AHA also said the WISeR model relies too heavily on outdated technologies like fax machines and mail, and that the program should instead require vendors to use FHIR-enabled APIs.  

Under the model, a denial can only be resubmitted or handled via peer-to-peer review. The AHA argues that traditional Medicare beneficiaries are entitled to the same rights as their MA counterparts and should have the ability to completely appeal adverse organization determinations.

Supporters Call the Plan a "No-Brainer"

Supporters of the model argue that traditional Medicare is plagued by a lack of accountability. The WISeR Model is a “no-brainer” that creates more accountability, according to Susan Dentzer, President and CEO of America’s Physician Groups (APG),

“As painful as utilization management may sometimes be, it’s delusional to think that traditional Medicare can duck more of it for much longer,” Dentzer wrote in an HFMA article. “First, people are often harmed by unnecessary healthcare, through increased or unrelieved pain, infections or other adverse effects. Second, all taxpayers foot the bill as do Medicare beneficiaries through higher premiums.”

According to Dentzer, the current review process in traditional Medicare, handled by Medicare administrative contractors, has been poorly implemented and has done little to stop fraud, waste or abuse. She notes that accountable care organizations (ACOs) have already been flagging questionable spending on items like urinary catheters and skin substitutes.

From her perspective, prior authorization is a proven and necessary tool to ensure services are clinically appropriate before they are rendered. The argument is that the lack of such utilization controls in the traditional Medicare program that could contribute to unsustainable spending.