The Wasteful and Inappropriate Service Reduction initiative from CMS will take effect next year, adding prior authorization requirements to traditional Medicare. Providers in Arizona, Washington, New Jersey, Texas, Ohio and Oklahoma will pilot the new protocol.
Here are eight things to know about the state of prior authorization and the upcoming program:
- CMS said Cohere Health, Genzeon Corp., Humata Health, Innovaccer, Virtix Health and Zyter will participate as vendors in the pilot.
- In November, six House Democrats introduced legislation to shut down the pilot.
- The AHA has been outspoken about delaying the program by at least six months. An Oct. 23 letter to CMS from the group outlined several recommendations for the initiative, such as establishing guardrails for AI use and altering the vendor payment methodology.
- CMS released a provider and supplier operational guide for the program Oct. 10. The guide notes that CMS is delaying the inclusion of deep brain stimulation and will reevaluate later. The document also outlined various steps for the providers who need to adapt to the prior authorization process.
- Earlier this year, CMS Administrator Mehmet Oz, MD, backed insurers aiming to simplify existing prior authorization processes. An AMA survey found physicians and staff spent about 12 hours per week on prior authorization paperwork.
- About a week after that move, CMS shared plans for its WISeR model, adding prior authorization to some traditional fee-for-service Medicare services. Some affected services include deep brain stimulation for Parkinson’s disease, epidural steroid injections for pain management and cervical fusion. The program will run from Jan. 1, 2026, through Dec. 31, 2031.
- Some lawmakers — House Democrats in particular — have scrutinized the program, particularly its use of AI to test methods for expediting prior authorization, and introduced a resolution opposing WISeR.
- The House Appropriations Committee advanced a 2026 spending bill with an amendment blocking funding for the pilot program. “Let’s not bring this nightmare to Medicare, the one program that seniors still count on for guaranteed straightforward care,” said Rep. Lois Frankel, D-Fla., who introduced the amendment during a Sept. 9 meeting.
