Jesse Smedley is a Principal of Oakbridge Insurance and the founder of iHealthBrokers. He founded iHealthBrokers in 2007, and Oakbridge acquired iHealthBrokers in 2025. He has spent nearly two decades teaching people how to save money on their health insurance and navigate Medicare, and he is the author of Medicare A to Z: Your Roadmap to Medicare.
Prior authorization is one of the biggest frustrations in health care. In the American Medical Association’s 2024 survey, 93% of physicians said prior authorization delays patient care, and physicians reported spending about 13 hours a week on prior authorization paperwork.
Until now, that was mostly a Medicare Advantage problem. Starting in 2026, prior authorization is showing up in Original Medicare too, and the early rollout has been rocky.
What CMS Is Doing
CMS launched a pilot program called WISeR, short for the Wasteful and Inappropriate Service Reduction Model. Its stated goal is to reduce fraud and waste and make sure Medicare pays only for appropriate care.
The model relies on outside technology companies, which use AI tools to help review requests. CMS says a licensed clinician must make any final decision not to approve a request. We first covered the announcement in Major Medicare Changes Coming in 2026 to Six States. Here’s where things stand now.
Where the Program Applies
WISeR started January 1, 2026, and is scheduled to run through 2031. It’s limited to six states:
- Arizona
- New Jersey
- Ohio
- Oklahoma
- Texas
- Washington
It applies only to people with Original Medicare, and only to a select list of services. If the model is considered successful, CMS could expand it to more states or more services.
Services on the list include knee arthroscopy for osteoarthritis, epidural steroid injections, cervical fusion, electrical nerve stimulators, other nerve stimulator implants and skin substitutes for wounds. These aren’t rare procedures. Many seniors rely on them for mobility and chronic pain management.
If a provider chooses not to request prior authorization, the claim can instead go through a medical review before Medicare pays it.
The Controversy
Providers already spend hours every week on administrative paperwork, which means less time with patients and more burnout. Adding prior authorization to Original Medicare means longer waits for approvals, possible delays in care and more administrative work for services that used to be routine.
The rollout has also caused confusion over which services need approval, since the requirement was new to providers who had never dealt with it under Original Medicare.
Financial Incentives
This program is driven by cost. CMS wants to reduce unnecessary spending and prevent fraud and overuse, and that’s a good goal.
But many providers worry that cost control will turn into more denials, slower approvals and less access to care. Part of that concern comes from how the vendors are paid: they receive a share of the Medicare spending they help avoid, adjusted for factors like timeliness and accuracy. Some of these companies also work on prior authorization for Medicare Advantage plans.
Is that a good thing or a bad thing? It depends on who you ask. The challenge is balancing efficiency with the risk of denying care that patients need.
What’s Happened Since Launch
Update (November 2026): WISeR has drawn pushback from both parties in Congress.
- In June 2026, the House Appropriations Committee voted unanimously to add language blocking funding for WISeR to its 2027 health spending bill. That bill has not become law.
- In July 2026, the Senate voted 46 to 50 against a resolution that would have overturned the model.
- Lawmakers and patient advocates have reported delays and denials in pilot states. CMS maintains that the model doesn’t change what Medicare covers.
For now, WISeR remains in effect. It’s still an early-stage pilot, and its full impact isn’t known yet.
Why This Matters for Original Medicare Beneficiaries
Historically, Original Medicare has meant no networks, no referrals and no prior authorization. Those are major selling points, especially compared with Medicare Advantage. This pilot chips away at one of Original Medicare’s biggest advantages: direct access to care without waiting for approval.
If you live in one of the six states, ask your provider before treatment: “Does this require prior authorization under the WISeR model?” Don’t assume approval is automatic. Confirm coverage before you schedule a procedure so you aren’t caught off guard.
This is especially important if you have a chronic condition, need frequent procedures or have a serious diagnosis that requires time-sensitive care.
Will the pilot improve efficiency or create more barriers to care? Only time will tell. But even if you aren’t affected today, it could expand beyond the pilot states and the current list of services if CMS considers it a success. If you’re still weighing your options, our Original Medicare vs. Medicare Advantage comparison and our guide to Medicare Supplement plans can help.
Get Help With Your Medicare Coverage
Have questions about how WISeR or prior authorization could affect your care? Our licensed brokers can review your coverage at no cost. Get your free quote or call us at (866) 260-9829.
