The Prior Authorization Divide

For nearly two decades, prior authorization was a defining feature of Medicare Advantage and largely absent from Traditional Medicare. A beneficiary who chose Original Medicare accepted lower benefits and higher cost-sharing exposure in exchange for freedom from utilization management. WISeR ends that deal for a targeted set of services and introduces a structural irony that has not gone unnoticed: an administration that has publicly criticized MA prior authorization practices for contributing to inappropriate denials is simultaneously building a PA program into fee-for-service Medicare. How the two regimes compare, and what the convergence signals for providers and beneficiaries, is the subject of this article.

How MA Prior Authorization Became a Policy Problem

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Prior authorization in MA began as a cost management tool and became a political one. MA plans are paid a capitated rate and bear the financial risk of covered services, which creates a structural incentive to scrutinize high-cost or high-volume services. PA is the operational expression of that scrutiny. By 2023, MA plans made 50 million prior authorization determinations across the enrolled population. KFF reported that nearly all MA enrollees, 99%, were in plans that required PA for at least some services, compared with 0.01 PA determinations per beneficiary in Traditional Medicare. A 2024 study found MA plans required PA for roughly 18% of Part B clinical services.

The OIG’s 2022 investigation identified the core problem with how MA PA was functioning in practice. Plans were denying prior authorization requests for services that met Medicare coverage criteria and that would not have been denied under Original Medicare. The investigation documented both prior authorization denials and payment denials that were clinically inappropriate, contributing to care delays and out-of-pocket costs for beneficiaries who pursued care anyway or whose providers resubmitted claims after service. The 82% overturn rate on appealed MA PA denials captures the magnitude of the problem: when beneficiaries and providers challenged decisions, more than four in five succeeded, which is evidence that the initial denials were frequently indefensible.

The administrative burden fell heavily on providers. AMA surveys documented physicians spending substantial time each week on PA requirements, and the specialty societies most affected by MA PA, orthopedics, dermatology, neurology, and interventional pain management, became among the most vocal critics. The provider argument was not that PA was categorically wrong, but that its design in MA created systematic friction for appropriate care without proportionate benefit in identifying genuinely inappropriate services.

CMS Administrator Mehmet Oz framed the problem in terms of coding behavior as well as access. At his confirmation hearing, he characterized MA PA as contributing to upcoding pressure, arguing that when PA denials are common, providers respond by intensifying documentation to capture medical necessity, which inflates coded acuity even for services that ultimately get approved. Whether this framing translates into regulatory action through CMS-4212-P’s final rule remains to be seen, but it signals an administration posture that is at minimum rhetorically opposed to MA PA expansion.

WISeR: FFS Adopts Prior Authorization

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WISeR launched January 1, 2026. It is a six-year CMMI model test running through December 31, 2031, operating in six states across four MAC jurisdictions: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington. The services subject to PA are narrow: skin and tissue substitutes, electrical nerve stimulators, knee arthroscopy for osteoarthritis, and spinal procedures, with skin substitute coverage limited to states and MAC jurisdictions with active skin and tissue programs. CMS selected these services based on documented fraud, waste, and abuse history, OIG work plan citations, CERT program findings, and the fact that MA plans already required PA for them, creating a baseline for comparison.

The rationale for the model is grounded in MedPAC’s estimate that Medicare spent $5.8 billion on low-value services in 2022, a figure that CMS attributes substantially to services in the WISeR target categories. A September 2025 OIG report found Medicare Part B spending on skin substitutes alone exceeded $10 billion in 2024, with documented fraud schemes and utilization patterns that standard post-payment review had failed to control. The combination of known fraud patterns and high expenditure made the targeted services defensible candidates for a PA intervention.

The contractor structure departs significantly from MA. WISeR participants are companies with experience in technology-enabled PA for commercial payers and MA plans, selected through a competitive application process that closed July 25, 2025. CMS announced selected participants on November 6, 2025. These contractors are compensated through a share of averted expenditures, meaning they receive a portion of the savings from denied or redirected services after appeals are fully adjudicated. Payments are delayed up to one year to avoid clawback obligations if appeals succeed. The financial incentive is for contractors to identify genuinely unnecessary services, not to maximize denial volume, since denied services that are overturned on appeal produce savings that reverse. CMS performs rigorous oversight and holds participants accountable through accuracy-based performance metrics.

The timeline for PA decisions is 72 hours for standard requests and 48 hours for expedited cases. Providers who prefer not to submit PA requests can submit claims after service delivery, but those claims go through detailed medical and documentation review by MACs rather than the streamlined PA track. The choice is prior authorization before service or intensive post-service scrutiny. Non-affirmation decisions must be reviewed by a licensed clinician before issuance. Providers retain existing Medicare FFS appeal rights.

Gold carding is planned but not yet active. CMS launched the gold carding or exemption program in 2026, targeting providers who achieve a 90% or higher provisional affirmation rate on PA requests. Providers who consistently demonstrate that their requests meet coverage criteria would be exempted from the PA requirement, shifting the PA burden toward providers with higher rates of inappropriate requests. The exemption threshold and assessment methodology were detailed in CMS guidance issued alongside model launch.

How the Two Regimes Compare

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The differences between WISeR and MA PA are more fundamental than scope alone.

WISeR covers four service categories in six states. MA PA covers whatever a plan determines requires PA, which as of 2024 included approximately 18% of Part B clinical services and extended into skilled nursing facility admissions, home health, specialty drugs, and durable medical equipment. The scope asymmetry is massive, and it runs in the direction that makes WISeR politically easier to defend: FFS PA is narrow and targeted; MA PA is broad and discretionary.

The contractor incentive structure in WISeR is specifically designed to reward accuracy over denial volume. A contractor that denies appropriate care will see those denials overturned on appeal and will lose the associated savings credit. This aligns the financial incentive with the policy goal in a way that the MA plan structure does not. A MA plan that denies PA for a covered service and wins the denial on low appeal rates captures the cost savings directly. A MA plan that is challenged and loses on appeal has absorbed administrative cost but may still have deterred some beneficiaries from pursuing care at all. The incentive environments are structurally different.

Gold carding as designed in WISeR creates a feedback mechanism that reduces burden for high-performing providers over time. MA plans are not required to implement gold carding, though some do voluntarily. The CMS-4212-P proposed rule would introduce new guardrails on MA PA, including continuity of care protections and appeal timeline requirements, but its final rule status as of early 2026 leaves the MA reform uncertain. If WISeR demonstrates that gold carding works at scale in FFS, the political and regulatory pressure on MA plans to adopt it grows substantially.

The 72-hour decision timeline in WISeR compares favorably to MA PA timelines, which under current regulation require decisions within 14 days for standard requests and 72 hours for expedited requests. WISeR’s standard timeline matches the MA expedited timeline, which providers in affected states will notice. The practitioner argument for WISeR is not that it is good but that it may be better designed than the alternative it is implicitly competing with.

Provider and Advocacy Response

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Provider organizations responded with alarm rather than nuance. The AMA’s core objection was categorical: any PA expansion in FFS increases administrative burden, and the administrative burden of PA is itself a harm independent of its clinical effects. Specialty societies whose members are most exposed, orthopedics and interventional pain management, raised concerns about care delays for patients who cannot wait 72 hours for an authorization decision, even while acknowledging that the services in scope have documented fraud problems.

Congressional opposition emerged quickly. Multiple members sent letters to CMS raising concerns about the model. The House Appropriations Committee adopted an amendment to the FY2026 Labor-HHS-Education appropriation bill that would prohibit funding for WISeR if enacted, though the status of that appropriation remains uncertain as of early 2026. Legislation introduced in the House would prohibit implementation outright. WISeR faces the same political environment that has made MA PA reform difficult: providers and their advocacy organizations are organized, engaged, and willing to use legislative channels.

Patient advocates expressed competing concerns. Beneficiaries who receive unnecessary or unsafe care under FFS without any utilization review bear clinical risk that PA is designed to reduce. Beneficiaries who need the services in scope and face authorization delays bear access risk. The access versus safety tradeoff is not falsifiable from the advocacy position and ultimately depends on how accurately the contractor identifies inappropriate services, a question that only model performance data will answer.

The dual eligible dimension is underappreciated in the public debate. Dual eligible beneficiaries who are enrolled in FFS, not in a D-SNP or other MA plan, will face WISeR PA requirements in the six covered states. They also face MA PA requirements if they transition to MA coverage. The coordination between the two regimes for a population that moves between coverage types, faces more complex medical situations, and has less capacity to navigate administrative processes is not addressed in the model design. CMS’s stated goal of alignment between WISeR and MA practices suggests this is a direction the agency is thinking about, but the operational details have not materialized.

The Gold-Carding Question

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Gold carding is the design element most likely to determine whether WISeR contributes to a better PA environment or merely expands it. A PA program that removes its own burden for demonstrated high performers is fundamentally different from one that applies uniformly regardless of provider track record.

In WISeR, the 90% affirmation threshold creates a meaningful standard. Providers who cannot meet it are, by the program’s logic, requesting services that are frequently inappropriate or inadequately documented, and those are exactly the providers on whom PA scrutiny is appropriate. Providers who meet it have demonstrated they understand coverage criteria and document appropriately, and exempting them from the PA process allows CMS to concentrate scrutiny where it belongs.

If WISeR’s gold carding program proves operationally effective at identifying compliant providers and reducing administrative burden for them, it becomes a template for a conversation about MA PA reform that the current regulatory environment has struggled to structure. The political leverage works as follows: if FFS can build a PA program with gold carding that functions without the denial-rate distortions observed in MA, the argument for why MA plans cannot do the same becomes harder to sustain. Whether CMS will apply that argument in its CMS-4212-P final rule, or whether the administration’s deregulatory posture will lead it to retreat from MA PA guardrails instead, is the open question that will define which direction the PA convergence runs.

Related Reading

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MCR-01_03 WISeR: Prior Authorization Comes to Traditional Medicare MCR-00_02 Original Medicare as Policy Choice MCR-07_03 Your Doctor and the New Prior Authorization World