Criticism Grows Toward CMS Prior Authorization Pilot Program

WASHINGTON—The Centers for Medicare & Medicaid Services (CMS) announced a new prior authorization pilot program that will require recipients of Medicare to receive prior approval before obtaining access to certain medical services. 

Called the “Wasteful and Inappropriate Service Reduction (WISeR)” model, the program is only due to run in six states (Washington, New Jersey, Oklahoma, Ohio, Texas and Arizona), the program has received attention and criticism from experts who say the program could do more harm than good.

When the program was originally announced, CMS said it will partner with companies specializing in enhanced technologies to test ways to help patients and providers avoid “unnecessary or inappropriate care.” 

“CMS is committed to crushing fraud, waste and abuse, and the WISeR Model will help root out waste in Original Medicare,” said CMS Administrator Dr. Mehmet Oz. “Combining the speed of technology and the experienced clinicians, this new model helps bring Medicare into the 21st century by testing a streamlined prior authorization process, while protecting Medicare beneficiaries from being given unnecessary and often costly procedures.”

In August, 17 Democrat lawmakers wrote a letter to Oz to raise concerns that the proposed prior authorization practices would prevent access to care and become a hindrance for those who need the care most.

“The use of prior authorization in Medicare Advantage shows us that, in practice, [this proposal] will likely limit beneficiaries’ access to care, increase burden on our already overburdened health care work force and create perverse incentives to put profit over patients,” the lawmakers wrote. “The Trump Administration publicly recognized the harm of prior authorization …And yet, not a week after these statements, CMS put forward a new proposal to increase the utilization of prior authorization in a type of health coverage that had seldom used the tactic before, replacing doctor’s medical knowledge with an algorithm designed to maximize care denial in order to increase profits.”

“I witnessed the ridiculous and ever-increasing obstructions caused by insurance companies to delay or deny care to patients,” said North Carolina Congressman Greg Murphy, who has an extensive career as a physician.

The model is not set to impact people enrolled in Medicare Advantage, and private companies involved in the program will be paid for their participation based on their “ability to reduce unnecessary or non-covered services.”

The letter asks for answers to the following questions:

• What criteria were used to select the six states for this model?
• What services will be subject to prior authorization in each state? Will the model operate on a statewide basis for all services and in all states or will there be variation among states (and if so please describe)?
• How will entities performing prior authorization be selected? What qualifications will be required to ensure that reviewers have appropriate expertise?
• How will patients and providers be educated about the new prior authorization requirements and appeals rights?
• What review of the contracted entities’ algorithms will occur to ensure that inappropriate denials of medically necessary care do not occur?
• What performance metrics will be required for entities performing prior authorization? How quickly must entities issue decisions? Will there be sanctions for participants that to not render decisions timely? Will prior authorization denials count as benefit denials that allow patients to access appeal rights?
• Has CMS studied how prior authorization in Traditional Medicare may increase rates of physician burden and burnout?

The WISeR model is set to be launched on Jan. 1, 2026 and will run for six years to measure its effectiveness, ending on Dec. 21, 2031. To read the full letter, click here.