Earlier this year, one of our long-standing clients, a solo pain management practitioner in Texas, asked us a question many providers are now raising:
“I’ve always relied on Traditional Medicare’s minimal prior authorization—what’s changing in 2026?”
Her concern led us to examine the Medicare Prior Authorization Program, formally called the WISeR (Wasteful and Inappropriate Services Reduction) Model.
- Would this slow down patient care?
- How much more paperwork would her team face?
- Could prior authorization delays hurt her practice’s cash flow?
Her questions mirror what thousands of independent practitioners are asking nationwide.
ℹ️ Note: For the purpose of readability and convenience, this blog uses the terms “Medicare Prior Authorization Program” and the “WISeR Model (Wasteful and Inappropriate Services Reduction)” interchangeably. Both refer to the same pilot program that CMS will launch in January 2026 under Traditional Medicare.
⚠️ Disclaimer: The insights shared in this blog reflect our assessment of the Medicare Prior Authorization Program (WISeR Model) based on currently available information. Every practice’s situation is unique, and no operational or financial decisions should be made without a customized consultation with an expert.
What is the Medicare Prior Authorization Program (WiseR Model) and why is CMS implementing it?
The Centers for Medicare & Medicaid Services (CMS) announced that beginning in January 2026, a prior authorization pilot program – the WISeR (Wasteful and Inappropriate Services Reduction) Model will launch as a six-year pilot in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington.
For decades, Traditional Medicare (Parts A & B) rarely required prior authorization, unlike Medicare Advantage plans. The WISeR Model changes that. CMS has framed the WISeR Model as a critical safeguard for the integrity of the Medicare program.
Its goals are to:
- Eliminate fraud, waste, and abuse by curbing medically unnecessary or inappropriate services.
- Reduce excess and unnecessary services to ensure care provided is clinically justified.
- Control Medicare spending through stricter oversight and smarter utilization of resources.
- Strengthen program integrity and compliance by promoting accountability across providers.
The program focuses on electronic prior authorization (ePA), requiring providers to submit requests digitally. AI will be used to review requests for compliance, but licensed practitioners will make the final decisions.
It is driven by a significant financial imperative; CMS cites research estimating that up to 25 percent of all U.S. healthcare spending is attributable to waste, with Medicare alone spending up to $5.8 billion in 2022 on services with little or no clinical benefit.
The agency intends to redirect healthcare spending toward services that demonstrably improve patient well-being and to “de-incentivize and reduce use of medically unnecessary care.”
For independent practices, the program represents more than added paperwork—it’s a shift that could reshape care delivery, revenue cycles, and patient trust.
Which Specific States and Services are Impacted Under the Medicare Prior Authorization WISeR Model?
CMS has flagged 17 targeted outpatient services for prior authorization across the pilot states of Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. These services span orthopedics, pain management, neurology, and wound care.Examples include:
- Epidural steroid injections for pain management(excluding facet joint injections)
- Cervical fusion
- Deep brain stimulation
- Electrical, sacral, vagus, and hypoglossal nerve stimulators
- Knee arthroscopy for osteoarthritis
- Percutaneous vertebral augmentation
- Skin and tissue substitutes
These services had historical patterns of overuse, fraud, or limited clinical benefit.
How Will the Prior Authorization Process Work?
Healthcare providers in the six pilot states must choose between two workflows:
- Pre-service prior authorization: Submit documents before the procedure. If approved, the procedure can be scheduled with confidence, and payment is guaranteed.
- Post-service pre-payment review – Perform the service first, but Medicare will hold the claim for review before releasing payment. This often leads to delays, additional documentation requests, and a higher risk of denial.
The process integrates AI for initial screening, but licensed clinicians make final determinations.
In reality, Pre-Service Authorization will be the only viable path. Post-service review may stall revenue for weeks and frustrate patients who experience delays.
Spotlight on Epidural Steroid Injections and the Medicare Prior Authorization Program
Epidural steroid injections (ESIs) are widely used to treat back pain and radiculopathy, and under WISeR, they will require prior authorization beginning in 2026.
Key implications:
- Tracking number required for every ESI under Medicare PA
- Documentation burden: Providers must prove medical necessity (failed conservative therapy, diagnostic imaging, functional impairment)
- Workflow changes: Staff will spend more time on submissions and appeals
- Patient delays: Scheduling will be pushed back until approvals are secured
- Exclusion: Facet joint injections are not included in WISeR’s prior authorization list
For patients, this means longer waits for pain relief. For practices, it’s a fundamental shift toward proving necessity before performing the procedure.
What are the Key Challenges and Opportunities Under the Medicare Prior Authorization Program?
Cash flow risks –
- Post-service reviews under the program can delay or deny payments.
- Small practices lack financial reserves to absorb interruptions.
- Even a few denials of costly procedures such as epidural steroid injections (ESIs) can strain the payroll.
- AMA survey data:
- 65% of physicians wait at least one day for PA decisions.
- 26% wait three or more days.
Administrative burden
- The Medicare Prior Authorization program requires detailed proof of medical necessity, including:
- Evidence of failed prior therapies.
- Supporting imaging reports.
- Documentation aligned with LCD/NCD requirements.
- Large health systems employ centralized prior authorization (PA) teams to handle this workload.
- Independent practices often depend on one or two staff members juggling multiple roles.
- According to the AMA, physicians already handle ~43 PAs per week—consuming nearly two staff days.
Front-loaded compliance
- Records must align exactly with Medicare’s Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs).
- The program’s AI-driven screening will automatically flag incomplete, unclear, or mismatched submissions.
- Documentation gaps can directly raise denial rates and expose practices to audits.
Patient dissatisfaction
- Delays in pain procedures like ESIs frustrate patients and contribute to poorer clinical outcomes.
- AMA (2023) survey findings:
- 94% of physicians report care delays tied to PA.
- 30% report adverse events resulting directly from PA delays.
Competitive disadvantage
- WISeR mandates electronic prior authorization (ePA).
- Larger systems have already invested in AI-driven claims tools, enabling faster approvals.
- Independent practices still relying on manual processes face:
- Slower turnaround times.
- Higher staff burnout.
- Lost efficiency compared to competitors.
Gold-carding potential
- Practices with consistently high affirmation rates may eventually qualify for “gold-carding” (on page 14 of the PDF), a CMS strategy that reduces repeated prior authorization requirements. While details for WISeR are still being developed, the principle is clear: practices that demonstrate strong compliance early may earn greater efficiency and relief over time.
For independent practitioners, this means today’s investment in meticulous documentation could pay dividends in reduced administrative burden tomorrow.
Why Is This Change Especially Significant for Independent Doctors Serving Medicare Patients?
Traditional Medicare has long been valued for low prior-authorization requirements (MarketWatch). This pilot challenges that norm, adding complexity and compliance pressure that independent practices, particularly in rural or underserved areas, may be under-prepared to tackle.
What Do Experts and Industry Leaders Say About This Pilot?
Critics warn WISeR “erodes one key advantage of Traditional Medicare” and may delay or deny care for seniors (MarketWatch).
CMS counters that its combination of tech and clinician oversight will reduce fraud and uphold care quality (Centers for Medicare & Medicaid Services)
What Can Independent Practices Do Now to Prepare for the WISeR Pilot?
- Audit workflows: Spot bottlenecks before WISeR launches.
- Adopt ePA tools: Automate submissions and reduce manual rework.
- Train staff: Ensure teams understand LCD/NCD documentation requirements.
How can PainMed-PA help Independent Practices Navigate the Medicare Prior Authorization Program?
At PainMed-PA, we know the WiseR pilot isn’t just another compliance requirement—it’s a shift that could affect the survival of independent practices.
Our role is to help practitioners adapt while safeguarding both patients and revenue.
We support practices by:
- Redesigning workflows to integrate WISeR efficiently
- Automating authorizations with AI-powered Prior Authorization tools
- Training staff to meet LCD/NCD standards, especially for high-impact services like ESIs
- Building patient communication strategies to reduce frustration and protect trust
- Stabilizing cash flow by minimizing denials and accelerating reimbursements
Our goal is to turn WISeR from a burden into an opportunity for efficiency, compliance, and patient-centered care.
FAQs about the Medicare Prior Authorization Program
ℹ️ Note: In the FAQ section, both “Medicare Prior Authorization Program” and “WISeR Model” are used. They mean the same thing: the pilot program CMS will launch in 2026.
Q1: What is the WISeR Model, and when does it begin?
It’s a pilot prior authorization program for Traditional Medicare, launching January 1, 2026, and running through December 31, 2031, inArizona, New Jersey, Ohio, Oklahoma, Texas, and Washington.
Q2. Which services require prior authorization under WISeR?
Seventeen outpatient services, including epidural steroid injections, cervical fusion, nerve stimulators, deep brain stimulation, knee arthroscopy, and skin/tissue substitutes. Facet joint injections are excluded.
Q3: Do providers have to submit prior authorization?
No, it’s optional. If they don’t, claims go into a post-service, pre-payment review—which may carry higher denial risk
Q4: Will AI make the final decision?
No. AI helps with initial screening, but licensed practitioners make final coverage decisions
Q5. How will epidural injections be impacted by prior authorization?
All ESIs will require prior authorization in 2026. Documentation, workflow changes, and patient wait times will increase.
Q6. Does WISeR apply to Medicare Advantage plans?
No. WISeR applies only to Traditional Medicare.
Q6. What is “gold-carding” in the Medicare Prior Authorization Program?
It’s an exemption for providers with consistently high affirmation rates, allowing them to skip repeated authorizations.
Q5: How might this affect independent practices?
Expect increased administrative workload, delayed payments, and potential patient treatment delays, especially in solo or small group settings.
Q6: What steps should practices take now?
Audit impacted services, train staff, upgrade documentation systems, track outcomes, and advocate with local professional bodies for support.
Q7. How can PainMed-PA help independent practices adapt?
PainMed-PA offers workflow redesign, automation, staff training, and PA support to protect revenue and patient satisfaction
Why Preparing Now for the Medicare Prior Authorization Program Matters
The Medicare Prior Authorization Program (WISeR Model) is not just a regulatory adjustment — it’s a fundamental change in how Traditional Medicare services will be delivered, documented, and reimbursed.
For independent practices, especially those performing procedures like epidural steroid injections, the stakes are high.
By acting now, auditing workflows, training staff, investing in electronic prior authorization tools, and educating patients, you can stay ahead of the January 2026 rollout.
With support from PainMed-PA, you can safeguard your revenue cycles, maintain patient trust, and continue thriving in a system that demands proactive compliance.
To learn how we can support your practice, call us today on (512) 868-1762. Visit us at https://painmedpa.com/
References:
- Centers for Medicare & Medicaid Services (CMS).
- Federal Register. Medicare Program: Implementation of Prior Authorization for Select Services for the Wasteful and Inappropriate Services Reduction (WISeR) Model
- Association of American Medical Colleges. CMMI Releases New Prior Authorization Model for Medicare
- American Hospital Association CMS Prior Authorization and Program Integrity Guidance
- MarketWatch Medicare will test using AI to help decide whether patients get coverage — which could delay or deny care, critics warn
- ACDIS Clinical Documentation Guidance on Medicare Prior Authorization
- NavaQuote. Medicare Prior Authorization Pilot Insights