Will prior authorizations for Original Medicare soon be required?
Yes and no
But it’s probably not as big a deal as you might think, and certainly nothing to panic over.
In this video I will talk about this new trial program for prior authorizations in Original Medicare and what it will mean for all of us on Original Medicare in the years to come. I am Specifically referring to Medicare’s new pilot program on prior authorizations that starts in January, 2026.
We have received a number of questions on this that will be answered in this video.
I will cover why the prior authorization program was initiated and what you can expect in the years ahead.
The intent of Original Medicare is to cover everything medically necessary to diagnose and treat any disease, condition or injury.
It’s that simple. But the key term in that mandate is “medically necessary”.
Medically necessarily means the procedure is safe and effective, not experimental (clinical trials are an exception), is accepted and furnished or delivered in accordance with accepted standards of medical practice.
If it meets the requirement for medical necessity, Original Medicare will cover it.
Medicare Advantage plans replace Original Medicare and are supposed to also cover everything that is medically necessary. But they found a way around that with the abuse of prior authorizations.
In health insurance, and as a Medicare recipient, when we hear the term “Prior Authorization” it brings out a lot of bad emotions like frustration and fear and makes one eye twitch. That’s because Medicare Advantage plans have been using prior authorization requests to deny or modify the services recommended by your doctor.
The insurance company motivation has always been one of profit. Because they are paid a flat monthly fee by the US Government based on your health history, the more medical claims they can modify, exclude or prevent, the more money they make.
So, for those of you on the edge of your seat wondering if Original Medicare is going to make our lives miserable by denying coverage for medically necessary treatments, let me put that fear to rest.
Original Medicare has had very limited prior authorization requirements since 2014, mostly focused on some durable medical equipment, with the intent of reducing waste and fraud.
I will repeat that. The primary intent of Original Medicare’s prior authorization program is to reduce waste and fraud by the medical community.
What is this new Medicare pilot program that starts in January?
Medicare WISer Program to Catch Waste and Fraud and Abuse
As I mentioned, Medicare has a new prior authorization requirements program that will start in January, 2026 for only a few select states (more on where in a moment). The program is called the Wasteful and Inappropriate Service Reduction Model or WISeR for short.
Here are three examples of what kind of fraud this program is designed to prevent.
Transnational Medicare Fraud
Involving Stolen Identities for Durable Medical Equipment: In 2025, authorities uncovered a scheme where a criminal organization used stolen identities to submit fraudulent claims for urinary catheters and other equipment, targeting Medicare. Nineteen defendants, including foreign straw owners and a banker, were involved, resulting in $10.6 billion in fraudulent claims.
Medicare Fraudulent Billing
Medicare Fraudulent Billing for Unnecessary Amniotic Wound Grafts: this was Discovered and charged in second quarter of 2024, this involved two owners of wound care companies and nurse practitioners billing Medicare for unnecessary amniotic wound grafts. The scheme led to $900 million in fraudulent claims.
Telemedicine and Opioid Distribution Fraud
Telemedicine and Opioid Distribution Fraud: In 2023, a nationwide enforcement action revealed fraudulent telemedicine and pharmaceutical schemes, including improper opioid distribution, where funds were misused for luxury items. Seventy-eight defendants were charged with over $2.5 billion in alleged fraud against Medicare and other programs.
So, where Medicare Advantage Plans may use or abuse prior authorization requirements to enhance average profits per person, Medicare is using prior authorizations to stop massive amounts of systemic fraud that are costing Medicare billions of dollars.
Ambulatory Medicare Services Subject to Prior Authorizations
Looking ahead, WISeR starting in January of 2026 Medicare will launch the Wasteful and Inappropriate Service Reduction model requiring prior authorizations for a select group of 17 categories of ambulatory services that have been abused or used fraudulently in the recent past.
Ambulatory services are defined as medical procedures or treatments provided on an outpatient basis, where the patient receives care without staying overnight in a hospital, such as clinic visits, diagnostic tests, minor surgeries in ambulatory surgical centers, or epidural injections.
Medicare’s new model uses data and artificial intelligence (AI) to target overuse, fraud and waste. The Artificial Intelligence analyzes patterns of service utilization to flag potential issues efficiently and expedite reviews.
The 17 Categories included in the WISeR program are:
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 (VCF)
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
According to CME – Center for Medicare and Medicaid Services, the suspected motivations for illegal overuse include financial incentives in fee-for-service payments that reward volume over value, defensive medicine where doctors order unnecessary tests for their protection rather than your health, or patient demands for more interventions like when patients ask for medicine they saw advertised on TV . Motivation also includes gaps in medical training leading to over-reliance on tests, or lack of coordinated care causing unnecessary duplicates. In case you were concerned I should stress that Artificial Intelligence assists in identification but does not make final decisions, humans review all suggestions for approvals.
The bottom line, with Original Medicare no one is tasked with reducing your care to increase profits. They are tasked with identifying fraud, waste and abuse. Most of that comes from people other than the patient.
Geographic Limitations to the Pilot Program
For now, the anti-waste model is limited to 17 categories of ambulatory services. I list those out in the show notes below.
Geographically, as of January 2026 the program will be limited to Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington
Medicare has noted these states were not selected because there are instances of higher fraud, but rather because they are states where the 17 categories of care occur often enough to generate the data needed to validate and test their model.
To be clear, the WISeR model is a small pilot program intended to run through 2031.
If this program is successful in either reducing overuse of unnecessary services, or improving Medicare without increasing costs, then it will be expanded both in scope of services and in the states it will be active in.
In addition, if the AI model shows itself to be effective, it can be used to monitor Medicare Advantage Plan Prior Authorizations to provide real time reports when such prior authorization requests are not necessary or interfere with the quality of care.
WISeR is a Voluntary Program
Lastly, this is a voluntary program. The WISeR program does not alter your benefits under Original Medicare. The program targets medical facilities and medical providers, not patients. You can only opt out by changing doctors to one who is not involved in the program or not using a medical facility that is involved with program.
It would take an act of Congress to make the WISeR program mandatory.
Original Medicare Prior Authorization’s Are Nothing to Fear
Original Medicare and Medicare Advantage plans can both use Prior Authorizations, but their intent and objective of prior authorizations are polar opposites.
Where one has a history of abusing prior authorizations to increase profits, the other uses prior authorizations to decrease fraud, waste and abuse and increase the quality and longevity of Medicare.
Medigap Seminars Insurance Agency Reviews.
Frequently Asked Questions (FAQ)
Inpatient hospital stays and surgeries will not require prior authorizations. The WISeR program can require prior authorizations only for procedures in the 17 ambulatory (outpatient) categories as listed above.
No, CT Scans are not among the group of services that are subject to the prior authorization process.
No, MRI tests are not among the group of services that are subject to the prior authorization process.
The WISeR program does not alter or limit your benefits under Original Medicare in any way.
Yes. But the only way to opt out is to switch medical providers or faciitiy. You cannot continue with a doctor that is part of the program and opt out.
The WISeR program is an experimental / pilot program that will run through 2031 and is limited to a small group of states. Geographically, as of January 2026 the program will be limited to Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington
