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JasonV59
Contributor ⭐
August 20, 2025

Prior Authorization for Select Services

  • August 20, 2025
  • 9 replies
  • 5641 views

Medicare Program; Implementation of
Prior Authorization for Select Services
for the Wasteful and Inappropriate
Services Reduction (WISeR) Model

 

Has anyone heard about this going into effect? Shouldn't we be concerned? It is going to impact 6 states to start with.

 

This is for standard Medicare.

 

New Jersey, Ohio, Oklahoma and Texas, Arizona and Washington.

 

It will mostly impact procedures that deal with pain mitigation.

 

 

    9 replies

    SereneSeagull
    SereneSeagull
    Community Champion ⭐⭐⭐
    August 20, 2025

    Just read it’s AI driven.  Hold on to your hats, bumpy road ahead possibly.  Scheduled staring Jan 1, 2026 and supposedly runs for 6 years.

    papawofboo
    papawofboo
    Community Champion ⭐
    August 22, 2025

    I thought it was already in effect. We have had to have approval for many years, even before we got on MC. 

    Wife's doctor send in for one, got turned down, he sent wife to another dr. who requested the same thing. Got approved. The way that was explained is that doctors in certain fields can get things approved while other can't. 

    Always remember to save the letter with the approval until you get the eob. 

    Papaw of Boo
    T
    TRL1111
    Community Champion ⭐
    August 22, 2025
    @papawofboo wrote:

    I thought it was already in effect. We have had to have approval for many years, even before we got on MC. 

     

    Yeah, before you got on Medicare.  Preauthorizations are common in employer-sponsored plans and plans bought on the individual market, and in fact that's a selling point for Advantage plans--people are already used to dealing with preauthorizations (and networks).  (Note that they don't say "people like it"--just that they're familiar with it.)

     

    And that's a selling point of Medicare--nobody getting in between you and your doctor when it comes to your care.  But that sort of freedom costs the system a lot of money, and a pathway for abuse by unscrupulous providers.

     

    The preauthorizations being instituted are new for traditional Medicare, which has always required some preauthorizations, but far fewer than Advantage.  In 2023, Medicare received 400,000 requests for preauthorization, while Advantage plans received 50,000,000, even though Medicare and Advantage had about the same number of members.

     

     

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