Traditional Medicare: Prior Authorization Might Be Headed Your Way
Category: Medicare
August 30, 2025 — Prior authorization is one of the biggest dissatisfactions with health insurance plans. It entails getting approval for certain kinds of procedures or treatments before they can happen, and is an unpopular part of many private and Medicare Advantage insurance plans. While the policy saves money for insurance companies and guards against unnecessary medical expenses, it is viewed as both a hassle and a barrier to important medical care. Delays or denials caused by the approval process can also have serious consequences.
Traditional Medicare is stepping into the game with a test program using Artificial Intelligence (AI). The pilot, using private contractors, would start in six states next year. It will concentrate on on a list of procedures that Medicare believes are too costly and have little to no benefit to patients. Spine surgeries and steroid injections seem to be some of the procedures that will be on that list.
What is upsetting to many people is that the reason why they selected Traditional Medicare (Part B) over a Medicare Advantage Plan (Part C) is that didn’t want to have to risk prior approval. And they paid higher premiums to get that privilege (many Medicare Advantage plans carry zero premiums and provide extra benefits like vision and dental coverage).
See the full article in the New York Times – Medicare Will Require Prior Approval for Many Procedures.
Comments on "Traditional Medicare: Prior Authorization Might Be Headed Your Way"
Mike says:
Reporting indicates the program functions poorly and is not providing the savings promised. https://healthcareuncovered.substack.com/p/ai-gatekeepers-in-medicare-wiser?publication_id=255152&post_id=196017345&isFreemail=true&r=6x3jh&triedRedirect=true&utm_source=substack&utm_medium=email
Meanwhile Advantage plans will be overpaid by $76 billion in 2026 with no significant plan to eliminate the wasteful overpayments and no plan to recover the $612 billion in overpayments made between 2007 and 2023.
Mike says:
A lack of AI oversight does not sound good to me: https://www.kff.org/patient-consumer-protections/regulation-of-ai-in-prior-authorization-and-claims-review-a-look-at-federal-and-state-consumer-protections/?utm_campaign=KFF-Private-Insurance&utm_medium=email&_hsmi=417520503&utm_content=417520503&utm_source=hs_email#2302b3c7-060e-4c93-ac97-bdfa2d5e4dc9
Mike says:
In a bipartisan amendment vote the House Appropriations Committee acted to block funding for the WISeR or similar models. The amendment said “The committee believes that any proposal to impose prior authorization requirements in traditional Medicare should be subject to robust congressional oversight and transparent evaluation of impacts on beneficiary access to care, provider burden and program costs.”
https://www.beckerspayer.com/policy-updates/house-committee-votes-to-defund-wiser-prior-authorization-pilot/?origin=PayerE&utm_source=PayerE&utm_medium=email&utm_content=newslette
Mike says:
In June Medicare ordered a company participating in the WISeR program in Washington to submit a Corrective Action Plan after failing to meet required turnaround times for reviewing treatment requests. This follows an investigation by local media that found necessary care was delayed for months. One 88 year old patient waited two months to have an an incorrect denial overturned while he dealt with back pain that prevented him from walking.
Mike says:
In a 50-46 vote along party lines the Senate rejected a resolution to terminate the WISeR program, 4 Senators did not vote.
The University of Washington Medical system reports average wait times for authorizations have increased from 1-3 days to 15-20 days under the WISeR program. https://www.fiercehealthcare.com/regulatory/ai-powered-prior-authorizations-medicare-have-greatly-delayed-care-wash-hospitals-say