Medicare prior authorizations off to a rocky start, providers say

Modern Healthcare – Thursday, January 29, 2026
By Bridget Early

Less than a month into the program that introduced prior authorizations to fee-for-service Medicare, providers say they are running into the kinds of problems they warned about last year.

The Centers for Medicare and Medicaid Services launched the Wasteful and Inappropriate Service Reduction Model, or WISeR, on Jan. 1. Under WISeR, vendors use artificial intelligence, machine learning and other technologies to review prior authorization requests for a limited set of procedures in six states through 2031. The agency touts the initiative as a means to reduce waste, fraud and abuse and predicts it will save $3 billion.

Providers report communication gaps and difficulty completing the prior authorization process, which were among the concerns industry groups expressed about when CMS announced the program in June.

“A lot of our fears have been realized, that there was insufficient time for these vendors to have their systems and their processes fully in place so that providers could leverage them appropriately by the start of the program,” said Terrence Cunningham, director of administrative simplification policy for the American Hospital Association.

Providers are already worried about delays in care delivery and irked by onerous administrative requirements. Some of the vendors have been helpful and CMS has promised to tweak the program and extend additional guidance, but providers say it’s been tough going so far.

“We were concerned that the contractors, the vendors, would not be ready with their portals and that it would not go smoothly. And from reports of our hospitals, it’s not,” said Ann-Marie Alameddin, president and CEO of the Arizona Hospital and Healthcare Association.

WISeR applies to services such as skin and tissue substitutes, electrical nerve stimulator implants, and arthroscopy for knee osteoarthritis, and is in effect in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington.

Companies such as Cohere Health and Innovaccer are administering the model for CMS. Providers can choose to send their prior authorization requests directly to their state’s vendors or follow their usual procedures.

The technology companies get to keep 10%-20% of the savings generated from prior authorization denials. Their compensation is also based on factors such as volume and speed, communications with providers, and health outcomes. WISeR vendors that deny necessary care will be penalized, CMS said.

“Our focus on the payer side is really on doing these automatic yeses as fast as humanly possible,” said Dr. Jeremy Friese, founder and CEO of Humata Health, which services Oklahoma.

CMS plans to introduce a “gold card” that exempts providers that secure a high percentage of prior authorization approvals, a spokesperson said.

Some providers still don’t even know the model exists and they all need more information about how it works, said Dr. Jayesh Shah, a hyperbaric medicine and wound care specialist in San Antonio and president of the Texas Medical Association.

Some hospitals are reporting challenges with prior authorization requests. It wasn’t immediately clear how providers were even supposed to submit them, said Jeb Shepard, director of policy at Washington State Medical Association.

Requests from TMC Health haven’t been going through, forcing the Tucson, Arizona-based nonprofit health system to spend time and money to resolve problems despite assistance from Zyter, the WISeR vendor in Arizona, said Julia Strange, vice president of community benefit.

In Washington, medical practices are hiring employees to manage the workload, Shepard said.

Health systems are still adapting to the new workflow, Alameddin said. “Hospitals want to expand service lines and meet community need. They don’t want to necessarily expand their prior authorization department,” she said.

Some vendors are working to inform and reassure providers. Humata Health has conducted direct outreach, produced webinars and created a webpage for providers, Friese said.

The AHA is pressing CMS for more details about how to comply with WISeR, such as how the auditing process will work, Cunningham said.

Providers will be subject to surveys, interviews and site visits to evaluate WISeR and CMS will begin publishing annual reports next year, the CMS spokesperson said.

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