Medicare Prior Authorization Getting WISeR? Five Essential Questions
On June 27, 2025, the Centers for Medicare and Medicaid Services introduced the WISeR model. This has generated an incredible number of discussions and questions. Here are answers to five of them.What is WISeR?What are the goals?
CMS wants to reduce fraud, abuse, and waste, including low-value care. The selected service codes no doubt are connected to these concerns. Here are just two examples.Why is CMS adding prior authorization to Original Medicare?
Contrary to a couple posts, prior authorization in Original Medicare is not new. Initially not part of the Social Security Act, the law was changed. Prior authorization has applied to Original Medicare for years.
For a long time, it focused mostly on power mobility devices (very prone to fraud) and procedures that might be considered cosmetic. For example, is rhinoplasty (nose surgery) necessary because the person can't breathe or selective because he doesn't like his nose? In 2020 and 2024, CMS expanded the list. Just as with the WISeR model, the current list of codes subject to authorization includes some with questionable medical necessity or low-value.Will this push Original Medicare closer to Medicare Advantage?
Some recent headlines reflect this concern.
'It's going to be just like Medicare Advantage, delay and deny.'
'CMS and insurers signed a pledge to reduce prior authorization and now they're doing this.'
There is no way to know for sure whether WISeR will turn Original Medicare into an Advantage clone. But that may not happen because there are some significant differences between this system and that of Medicare Advantage.Are there any big concerns?
With any new project, there will be concerns. Besides the one about pushing Original MC toward Advantage, here are three that pop up quite regularly:There is no denying something needs to be done to control the fraud and waste in Medicare. CMS recognizes that it will take to come up with a system and guardrails to achieve the goals while reducing provider burden and avoiding beneficiary harm. CMS has six years to get this right.
There is another WISER model. It stands for Watch, Pay attention, Interpret, Engage and Reflect, and helps to control strong emotions. It may be a wise thing to apply this model as we work through the CMS' attempt to become WISeR.
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