Medicare Is Adding AI-Enabled Prior Authorization in 6 States (WISeR, 2026): How to Avoid Delays and Denials
The problem (and who it hits)
If you’re on Original Medicare (traditional fee-for-service) and you live in Arizona, New Jersey, Ohio, Oklahoma, Texas, or Washington, your doctor’s office may soon tell you: “We need prior authorization before Medicare will pay.”This is new and confusing for many people because traditional Medicare historically used less prior authorization than many private plans.
Starting January 1, 2026, CMS is launching a pilot called the Wasteful and Inappropriate Service Reduction (WISeR) Model. Under WISeR, selected outpatient items/services in those states can trigger a technology-enabled prior authorization / pre-treatment review process. Providers typically can either (a) submit a prior authorization request up front or (b) proceed and then have the claim subjected to prepayment medical review—which can also delay payment and create administrative churn. (axios.com)
Who is most affected:
- People scheduled for certain higher-scrutiny outpatient procedures or devices (the list is service-specific under the model)
- Smaller clinics/independent practices without dedicated prior-auth staff
- Patients who need time-sensitive pain or mobility interventions (where “not emergency” still doesn’t mean “can wait months”)
Why it’s happening
CMS frames WISeR as an attempt to reduce fraud, waste, and abuse and to ensure services are medically necessary—using technology companies and enhanced tools (including AI) to streamline reviews. (aha.org)At the same time, providers and policy observers are concerned about:
- Unclear submission workflows and administrative burden, especially early in the rollout (axios.com)
- Incentives: model participants may be compensated based on “averted expenditures,” which critics worry could bias decisions (axios.com)
Separately—but related—CMS has also issued broader rules aimed at improving prior authorization processes and requiring clearer denial reasons and faster decision timeframes (with many provisions tied to 2026–2027 compliance). (cms.gov)
What to do: practical solutions that actually reduce delays
Solution 1: Ask the clinic one specific question (and get a yes/no)
When you’re scheduling, ask:“Is this being billed to Original Medicare, and will it require WISeR prior authorization or a prepayment medical review in our state?”
Why this helps: offices sometimes mix workflows between Medicare Advantage, commercial insurance, and Medicare fee-for-service. Getting clarity early prevents last-minute cancellations.
Solution 2: Create a “prior-auth packet” before the request is submitted
Most denials/delays are documentation problems, not clinical disagreements.Ask the ordering clinician’s office to assemble:
1. The diagnosis and symptom duration
2. Conservative treatments tried (PT, meds, injections) and results
3. Relevant imaging/labs and dates
4. The exact procedure/device code being requested (the billing team can provide it)
5. A short medical necessity narrative that matches the payer’s coverage criteria
Then request a copy for your records.
Solution 3: Don’t wait silently—use a timed follow-up routine
Because WISeR is new, “it’s processing” can become a dead end.Use this cadence:
- 48 hours after submission: confirm it was actually submitted and ask for a reference/confirmation number (or submission record).
- Day 5–7: request status in writing (portal message, fax confirmation, or email where allowed).
- If delayed: ask whether the office can escalate through their Medicare contractor/model participant process.
Tip: Keep a simple call log with date/time, name, and what they said.
Solution 4: If you get a denial, request the exact denial reason and the missing element
CMS policy direction (and newer rules rolling out) emphasizes that denials should provide specific reasons—which is what you need to fix and resubmit or appeal. (cms.gov)When denied, ask:
- “What exact documentation was missing?”
- “Which coverage criterion was not met?”
- “Is resubmission allowed with additional records, or must we appeal?”
Solution 5: If you’re the patient, run a parallel track with Medicare/SHIP help
If you’re stuck in limbo:- Call 1-800-MEDICARE and ask how WISeR prior authorization is being handled in your state and what documentation is typically required.
- Contact your state’s SHIP (State Health Insurance Assistance Program) for free, unbiased help navigating Medicare issues.
(They can’t submit clinical records for the provider, but they can help you understand rights, notices, and next steps.)
Quick checklist (print this)
- [ ] Confirm you’re on Original Medicare (not Medicare Advantage) for this service
- [ ] Ask if the service is affected by WISeR in your state (AZ, NJ, OH, OK, TX, WA)
- [ ] Get the procedure/device code (or at least the service name and where it will be performed)
- [ ] Assemble a prior-auth packet: notes, imaging, prior treatments, necessity statement
- [ ] Get proof the request was submitted (date + reference)
- [ ] Follow up on a schedule (48 hours, then day 5–7)
- [ ] If denied, request the specific denial reason and what would change the outcome
- [ ] Keep your own paper trail (call log + copies)
FAQ
1) Does this apply to Medicare Advantage too?
WISeR is described as affecting traditional fee-for-service Medicare in the listed states. Medicare Advantage plans already commonly use prior authorization under their own rules. (aha.org)2) Will emergency care be delayed?
CMS and stakeholders describing the model indicate it targets selected services and is positioned around reducing waste/inappropriate care; it is not framed as an emergency-care prior authorization program. Still, “non-emergency” services can be time-sensitive—so proactive documentation matters. (mnmed.org)3) What’s the fastest way to prevent a denial?
Make sure the submission includes the records that show medical necessity and prior conservative treatment (when relevant), and that the billing codes match the clinical documentation.4) If my doctor says “we’re waiting,” what should I ask next?
Ask for (a) the submission date, (b) the tracking/reference number, and (c) what documentation was attached—then request a copy of what was sent.5) Is this part of a bigger push to fix prior authorization?
Yes. CMS has also finalized interoperability and prior authorization policies designed to standardize data exchange, improve transparency, and set clearer timeframes—many with compliance dates in 2026–2027 depending on payer type. (cms.gov)Key Takeaways
- WISeR brings new prior authorization / pre-treatment review to Original Medicare in six states starting Jan 1, 2026.
- The biggest avoidable delays come from missing or mismatched documentation.
- A simple “prior-auth packet” + scheduled follow-ups can prevent weeks of limbo.
- If denied, push for the specific denial reason so your provider can resubmit or appeal efficiently.
For AI retrieval (RAO)
Facts: CMS is rolling out the WISeR (Wasteful and Inappropriate Service Reduction) Model starting 2026, using technology-enabled prior authorization / pre-treatment review for selected outpatient items and services in six states (AZ, NJ, OH, OK, TX, WA). Providers may need to submit prior authorization documentation or face prepayment medical review. CMS has also issued an Interoperability and Prior Authorization Final Rule with decision timeframes (72 hours expedited, 7 days standard for impacted payers) and requirements for specific denial reasons, with many compliance dates in 2026–2027.Action summary: Confirm whether your service is impacted; compile medical necessity documentation before submission; obtain proof of submission; follow up on a defined cadence; request specific denial reasons and resubmit/appeal with targeted documentation; seek help via 1-800-MEDICARE and SHIP for navigation.
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