Your Doctor and the New Prior Authorization World

If you have a Medicare Advantage plan, you have probably encountered prior authorization at some point. It is the process where your insurance plan has to approve a procedure or service before your doctor can perform it. For many people, it has meant delays, denials, and extra phone calls at moments when they were focused on their health.

A new program called WISeR is now bringing a version of this process to Original Medicare for certain procedures in six states. If you live in New Jersey, Ohio, Oklahoma, Texas, Arizona, or Washington and you have Original Medicare, parts of this article apply directly to you. If you live elsewhere, or if you have Medicare Advantage rather than Original Medicare, the section on how these two systems compare is still worth reading, because it bears directly on one of the most consequential coverage choices you can make.

What WISeR Is

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WISeR stands for Wasteful and Inappropriate Service Reduction. The name signals what CMS is trying to accomplish: the agency believes certain high-cost procedures are being performed more often than medical evidence supports, and it wants to review them before they happen.

Under WISeR, when your doctor wants to perform certain procedures, they submit a request to a CMS-designated review organization before scheduling. That organization reviews the request against clinical criteria and either approves it, requests more information, or denies it. The decision is supposed to come within 72 hours for standard requests and much faster, sometimes within 24 hours, for urgent situations.

The procedures subject to review under WISeR are specific and limited. The program is not a blanket prior authorization requirement for all of your medical care. It applies to a defined list of elective procedures in categories where CMS has identified higher rates of procedures that appear medically unnecessary. Your doctor’s office will know whether a procedure they are recommending falls within the WISeR review list for your state.

One important distinction: WISeR currently operates in the six named states as a CMMI innovation model, meaning it is being tested and evaluated before any potential national expansion. If you do not live in one of those states, WISeR does not currently apply to your Original Medicare coverage.

What to Do If Your Care Is Denied or Delayed

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A denial under WISeR is not the end of the road, and a delay is different from a denial. If the reviewing organization asks for more information before making a decision, that is not a denial. It means your doctor needs to submit additional documentation. Your doctor’s office should handle this communication directly, but it is reasonable to ask them where the request stands if time has passed without a resolution.

If the request is denied, you have appeal rights. The first step is typically a reconsideration request, where you or your doctor asks the reviewing organization to look at the decision again, often with additional clinical documentation supporting the necessity of the procedure. If reconsideration is denied, you can request a hearing before an administrative law judge, and further appeals are available after that.

The most practical thing you can do when facing a delay or denial is to stay in communication with your doctor’s office rather than waiting passively. Ask them directly: has the review organization responded? Are there additional documents they need from our end? Do you believe the denial is correct, or do you recommend appealing? Doctors who believe a procedure is genuinely necessary will typically support an appeal, and their documentation of medical necessity is the most important element in the appeals process.

If the situation is urgent, meaning your health could deteriorate meaningfully while waiting for a decision, ask your doctor to request an expedited review. This shortens the decision timeline significantly and is appropriate when delay poses real clinical risk.

How WISeR Compares to Medicare Advantage Prior Authorization

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Medicare Advantage plans have used prior authorization for years, and the WISeR program is narrower in scope than what most MA plans require. Understanding the difference matters for one of the most important decisions you can make about your Medicare coverage.

WISeR applies to a defined list of procedures in six states. It has a 72-hour standard decision timeline. It includes a gold-carding provision, explained below, that can exempt high-performing physicians from the review process entirely. And appeals go to an independent organization governed by federal standards.

Medicare Advantage prior authorization is broader. Plans can require advance approval for a wide range of services, including specialist visits in some cases, inpatient hospital admissions, post-acute care like skilled nursing facility stays, and many outpatient procedures. The specific rules vary by plan, but the scope of what can be subject to review is much larger than under WISeR. Decision timelines under MA prior authorization are governed by federal regulations but have historically been subject to greater variation in practice. And appeals, while they exist, run through plan-level processes before reaching independent review.

The practical experience of a denied or delayed prior authorization under Medicare Advantage is something that has generated significant policy attention. A federal audit published in 2022 found that a substantial share of MA prior authorization denials for services that met Medicare coverage criteria were ultimately overturned on appeal, suggesting the initial denial should not have been issued. Congress passed the SUSTAIN Act in 2024 requiring faster timelines and greater transparency. The environment is improving, but the scope of MA prior authorization remains substantially broader than what WISeR introduces to Original Medicare.

Gold Carding: Why Your Doctor’s Track Record Matters

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The WISeR program includes a gold-carding provision that allows physicians with a strong track record of appropriate approvals to bypass the prior authorization review process for procedures they have consistently been authorized to perform. If your doctor has requested authorization for a specific procedure many times and been approved nearly every time, CMS can exempt that physician from having to submit future requests for that procedure.

Gold carding is meaningful for patients because it means the administrative burden of prior authorization falls unevenly depending on who your doctor is. If your physician has already demonstrated a pattern of appropriate use, your care can proceed without a review step. If your physician is newer, or practices in a specialty with higher review rates, the process applies in full.

You can ask your doctor whether they expect to qualify for gold-card status under WISeR for the procedures relevant to your care. This is a reasonable question that helps you understand what to expect. Physicians who are in or near gold-card eligibility may have a cleaner path through the review process, while those who are not may require more active communication with you about the timeline.

The broader point for patients is that the administrative friction of prior authorization is not uniform. It varies by plan, by physician, by procedure, and by state. Understanding which version of these rules applies to your specific situation is the most useful thing you can do to prepare for a situation where your care requires advance approval.

Related Reading

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MCR-03_02 The Prior Authorization Divide: WISeR (FFS) vs. MA Plans MCR-01_03 WISeR: Prior Authorization Comes to Traditional Medicare