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August 2025 Original Medicare Prior Authorization Requirement In the Advocate August 2025: Robby Stern CMS Expands Prior Authorization in Original Medicare Washington One of Six Designated States Robby Stern The Centers for Medicare & Medicaid Services (CMS) announced on June 27, “The CMS Launches New Model to Target Wasteful, Inappropriate Services in Original Medicare.” We know from a study by the Medical Payment Advisory Commission (MEDPAC) that Medicare Advantage (MA) overcharges the Medicare Trust Fund annually at least $80 billion per year. One would think wasteful inappropriate services must exceed that number or why would they be prioritizing expanding prior authorization in Original Medicare? (A PNHP study estimates overcharges are much higher, up to $140 billion annually.) MEDPAC estimates that up to $5.8 billion in Medicare spending in 2022 was spent on services with minimal benefit. Five billion eight hundred thousand is a lot of money, but it is approximately 7 percent of $80 billion overpayments to MA. We don’t know why they chose to focus on the much smaller amount possibly lost to "fraud, waste, and abuse.” Maybe they are trying to level the playing field in the wrong direction. Maybe they secretly want more of us in Medicare Advantage so they plan to add more prior authorizations into Original Medicare. We don’t know their motives, but below are excerpts from what they did say. "The Centers for Medicare & Medicaid Services (CMS) is announcing a new Innovation Center model aimed at helping ensure people with Original Medicare receive safe, effective, and necessary care. Through the Wasteful and Inappropriate Service Reduction (WISeR) Model, CMS will partner with companies specializing in enhanced technologies to test ways to provide an improved and expedited prior authorization process relative to Original Medicare’s existing processes, helping patients and providers avoid unnecessary or inappropriate care and safe- guarding federal taxpayer dollars… “'CMS is committed to crushing fraud, waste, and abuse, and the WISeR Model will help root out waste in Original Medicare,' said CMS Administrator Dr. Mehmet Oz. 'Combining the speed of technology and the experienced clinicians, this new model helps bring Medicare into the 21st century by testing a streamlined prior authorization process, while protecting Medicare beneficiaries from being given unnecessary and often costly procedures…. “'Low-value services, such as those of focus in WISeR, offer patients minimal benefit and, in some cases, can result in physical harm and psychological stress,' said Abe Sutton, Director of the CMS Innovation Center. 'They also increase patient costs, while inflating health care spending.' "The WISeR Model will test a new process on whether enhanced technologies, including artificial intelligence (AI), can expedite the prior authorization processes for select items and services that have been identified as particularly vulnerable to fraud, waste, and abuse, or inappropriate use. These items and services include, but are not limited to, skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy for knee osteo- arthritis. The model excludes inpatient- only services, emergency services, and services that would pose a substantial risk to patients if significantly delayed. "Companies selected to participate in the model will operate in assigned geographic regions and must have clinicians with appropriate expertise to conduct medical reviews and validate coverage determinations. Importantly, while technology will support the review process, final decisions that a request for one of the selected services does not meet Medicare coverage requirements will be made by licensed clinicians, not machines. "Model participants will receive payments based on their ability to reduce unnecessary or non- covered services (inappropriate utilization) and lower spending in Original Medicare. … "The WISeR Model will not change Medicare coverage or payment criteria. Health care coverage for Original Medi- care beneficiaries remains the same, and beneficiaries retain the freedom to seek care from their provider or sup- plier of choice… The WISeR Model does not impact people enrolled in Medicare Advantage." Trying to cut through the bureaucratic writing, what they are saying is CMS is changing Original Medicare coverage(which they deny) by expanding the list of medical treatments recommended by our providers subject to prior authorization beginning in 2026. CMS will contract with private, no doubt for-profit companies that will determine if the recommended treatment is unnecessary or inappropriate and/or constitutes waste, fraud, and abuse. The contractor may utilize AI to make the determination subject to a final decision by a licensed clinician that works for the contractor. These companies are essentially “bounty hunters." They are compensated based on their record of denying care and reducing spending in original Medicare despite the data that shows Original Medicare spends 22% less per patient than Medicare Advantage. Introducing “bounty hunters” into Original Medicare... what could possibly go wrong?! On June 23, HHS Secretary Kennedy and CMS Administrator Oz announced an insurance industry voluntary pledge to fix what they termed the broken prior authorization system in Medicare Advantage and Medicaid. The voluntary agreement with Medicare Advantage and Medicaid insurers addressed time limits for decisions on prior authorization. Standard decisions are to be made within seven days. Urgent medical requests are to be made within 72 hours. The appeals process for denials, if necessary, extends the time before the Medicare/Medicaid beneficiary receives the treatment the provider has recommended. This is a voluntary program for insurers participating in Medicare Advantage. The WISeR Model, which expands prior authorization in Original Medicare, is mandatory in the six designated states. Neither beneficiaries nor providers can opt out. PSARA will launch an effort, with our national allies, to stop WISeR before it starts in 2026. Robby Stern is President of the PSARA Education Fund and serves on the PSARA Executive Board. BACK TO THE ADVOCATE

Puget Sound Advocates for Retirement Action (PSARA) Archive collection of PSARA Advocate Newsletters (a monthly publication) on current issues in the area of Social and Economic Equity, Environment, Labor Justice. Advocate Newsletter Print Version

The Retire Advocate < Back to Table of Contents January 2026 PSARA 2026 Legislative Agenda Click here to download PSARA Leg. Agenda pdf Click here to download talking Points PSARA is a multi-generational grass roots organization advocating for all people, and seniors in particular, being able to live their lives with economic security, dignity, and respect. Healthcare PSARA believes that comprehensive, affordable, accessible, and culturally appropriate health care is a fundamental human right. Promote Leveling the Playing Field in Medicare, SJM 8002 Protect against healthcare program cuts and advance immigrant health equity and food security (budget) Regulate the use of Prior Authorization in healthcare decisions, SB 5395 / HB 1566 Climate and Environmental Justice PSARA supports the right of all people to live and work in a clean and healthy environment. Divest Washington State Investment Board funds from fossil fuels, No Coal Act SB 5439 Increase environmental justice by improving government decisions, Curb Act HB 1303 / SB 5380 Create standards for Data Center operations Fiscal Reform and Revenue PSARA supports a state budget that is transparent, pays a living wage to state workers, and provides services that help our people, economy, and environment thrive. Support progressive revenue HB 2100 Well Washington Fund Housing and Homelessness PSARA supports keeping people housed, building more low-income housing, and preventing homelessness in the first place. Workers’ Rights and Economic Justice PSARA supports legislation that promotes healthy families and workplaces. Extend unemployment benefits to undocumented workers SB 5626 / HB 1773 Expand Working Families Tax Credit HB 1214 / SB 5768 Strengthen Paid Family & Medical Leave financing Promote Washington Future Fund pilot (Baby Bonds) SB 5541 Provide greater security to Washington workers against ICE practices on the job (Immigrant Worker Protection Act) SB 5822 / HB 2015 Community Safety and Justice PSARA supports legislation that promotes community safety and justice for all of our community members. Ensure proper identification of law enforcement (No Secret Police Act) SB 5855 / HB 2173 < Back to Table of Contents