Original Medicare’s New Prior Authorization Rules

Original Medicare’s new prior authorization rules are set to begin in 2026. Typically, Original Medicare (Parts A and B) does not require prior authorizations, but changes are coming. This is a key difference compared to Medicare Advantage (Part C) plans, which often require prior authorization for various services.

The Center for Medicare and Medicaid Innovation (CMMI) on June 27, 2025, announced details for the new Wasteful and Inappropriate Service Reduction (WISeR) Model.

The WISeR Model was created to combat fraud, waste, and abuse. The program will run for six years beginning in 2026. It will test prior authorization for additional Part B services in Original Medicare for providers in the following states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington.

The goals of the WISeR bill aim to:

• Focus health care spending on services that will improve patient well-being.
• Apply commercial payer prior authorization processes that may be faster, easier, and more accurate.
• Increase transparency of existing Medicare coverage policy
• De-incentivize and reduce the use of medically unnecessary care

Under the model, providers in those states will have a choice of whether to submit a prior authorization request or undergo a post-service prepayment medical review for specific items and services. Providers who choose the prior authorization option may either submit the request directly to a model participant or submit the request to their Medicare Administrative Contractor, which will forward the request to the model participant. Model participants are companies “with expertise managing the prior authorization process for other payers using enhanced technology like AI” and “machine learning.” In addition, model participants are required to have clinicians with expertise to conduct medical reviews to validate determinations. Companies hired to manage the initiative will be paid based on the amount of money they save the federal government by preventing unnecessary or non-covered payments.

The core objective of the WISeR model is to prevent fraud, waste, and abuse by focusing on those factors that significantly impact Medicare. Is this exactly doing that?

What is causing the most waste, fraud, and abuse, prompting Medicare’s new prior authorization rules and the WISeR program?

It’s durable medical equipment (DME).

Recently, federal investigators claimed that thieves billed Medicare $10.6 billion for durable medical equipment, including walkers, wheelchairs, oxygen equipment, catheters, and diabetic shoes that were never used or received. This was all durable medical equipment.

If you compare that with the 17 services listed in the WISeR model, these services have never been at the center of any fraud schemes in the history of Medicare. If the new model is rolled out to the entire country with the intent of denying as many claims as possible, seniors requiring these not-so-common services are in trouble.

Here’s the list:

• Electrical nerve stimulators
• Sacral nerve stimulation for urinary incontinence
• Phrenic nerve stimulator
• Deep brain stimulation for essential tremor and Parkinson’s disease
• Vagus nerve stimulation
• Induced lesions of nerve tracts
• Epidural steroid injections for pain management
  • excluding facet joint injections
• Percutaneous vertebral augmentation (PVA) for vertebral compression fracture
• Cervical fusion
• Arthroscopic lavage and arthroscopic debridement for the osteoarthritic knee
• Hypoglossal nerve stimulation for obstructive sleep apnea
• Incontinence control devices
• Diagnosis and treatment of impotence
• Percutaneous image-guided lumbar decompression for spinal stenosis
• Skin and Tissue Substitutes
  • Application of bioengineered skin substitutes to lower extremity chronic non-healing wounds
  • Wound Application of cellular and/or tissue-based products (CTPs), lower extremities

What are the incentives?

The incentive is in the number of claims denied, saving Medicare money! Participants in the model will receive a percentage of the reduction in expenditures, or savings, that can be directly attributed to Medicare’s new prior authorization rules review process in their applicable region. So, who are these “participants?”

Participants in the WISeR model are companies that apply emerging technologies (A.I.) to clinical and claims processing solutions and have experience managing the prior authorization process for other payers, including insurers offering Medicare Advantage (Part C) plans, with a demonstrated ability to apply such technology to the payment processes used under Original Medicare (Parts A and B).

In June 2025, Dr. Oz held a huge press conference discussing the negative impact of prior authorization on Medicare Advantage (Part C), employer, and Obamacare (Marketplace) plans, but now his tone has changed.

Extensive utilization management approaches that “other payers” and the government want to employ more of are likely key contributors to why those enrolled in Medicare Advantage plans receive over 9% fewer low-value care services than those enrolled in Original Medicare. It’s all about preserving the Medicare Trust Fund, but with your health and well-being at stake.

What’s next?

We will continue to monitor this and share updates regarding Medicare’s new prior authorization rules.

If you have questions about Medicare plans where you live, we can help.

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