WISeR and Medicare Advantage Prior Authorization: What’s Changing in 2026

Few issues create more frustration for providers than prior authorization (PA). It delays care, creates administrative headaches, and slows down reimbursement. In 2026, prior authorization reform will reshape both Traditional Medicare and Medicare Advantage (MA) in ways that every practice and laboratory needs to prepare for.

Why Prior Authorization Is Under Scrutiny

Prior authorization was originally designed to control costs and prevent unnecessary services. But over time, it has become a top source of provider complaints and patient access delays. A 2024 AMA survey found that 89% of physicians reported prior auth often or sometimes leads to delays in patient care, while nearly one-third said it has led to a serious adverse event for a patient.

In response to growing scrutiny, CMS is making major changes in 2026 — starting with the WISeR pilot program in Traditional Medicare and stricter rules for all Medicare Advantage plans.

The WISeR Model: Traditional Medicare Pilot (2026–2031)

WISeR stands for Wasteful and Inappropriate Service Reduction. Beginning January 1, 2026, CMS will launch this six-year pilot program through the Center for Medicare and Medicaid Innovation (CMMI).

Key Features:

• Purpose: Test whether advanced technologies like AI can expedite PA and reduce fraud, waste, and abuse.
• Duration: January 2026 – December 2031.
• Scope: 17 outpatient services identified as overused or high-risk for fraud.
• Services include:
  
  • Facet joint procedures for back pain

• • Epidural steroid injections

• • Nerve and muscle testing

• • Electrical and spinal cord stimulators

• • Deep brain stimulation

• • TAVR procedures

• • Arthroscopic debridement for knee osteoarthritis

• • Vertebroplasty/kyphoplasty

• • Skin graft substitutes for chronic wounds

• • Medical botox and incontinence devices

• Technology + Human Review: AI will screen requests, but all denials must be reviewed by a licensed clinician.
• Geography: Pilot states include Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington.
  
  

Implications for Practices

For providers in WISeR states, this means more administrative work, higher documentation standards, and potential delays in reimbursement. High-volume specialties like pain management and orthopedics will feel the greatest impact.

Medicare Advantage (MA): New Nationwide Rules in 2026

In parallel, CMS is tightening rules for Medicare Advantage plans beginning in 2026.

Key Changes:

• Tighter Timelines:
  
  • Standard PA decisions must be made within 7 calendar days.

• • Expedited requests must be resolved within 72 hours.

• Transparency: MA plans must share data on PA outcomes with CMS.
• Beneficiary Protections:
  
  • Medical necessity determinations must be honored.

• • Loopholes in appeals processes are being closed.
    
    

Why It Matters

For providers, this means less guesswork — but also a greater need to meet documentation and clinical criteria precisely. MA plans will be under scrutiny, and providers who fail to align with rules risk delays or denials.

The Bigger Picture

Between WISeR and MA reforms, prior authorization will no longer be business as usual. For practices, labs, and patients, the stakes are higher than ever:

• More complexity in workflows, especially in WISeR pilot states.
• Higher compliance risk if requests aren’t documented thoroughly.
• Potential cash flow delays if PA processes aren’t automated.
  
  

How to Prepare for 2026

Providers should start building resilience now:

• Audit PA workflows to identify bottlenecks.
• Train staff on the 17 WISeR-impacted services and new MA timelines.
• Automate PA submissions with tools that integrate payer rules directly into RCM workflows.
• Track PA outcomes to improve appeal success rates.
  
  

Get the Full 2026 State of the Revenue Cycle Whitepaper

This blog gives you a high-level view of what’s changing in prior authorization. But it’s only one piece of the 2026 puzzle.

Our new flagship whitepaper — Resilience Through Partnership: The 2026 State of the Revenue Cycle — provides:

• A detailed breakdown of WISeR and MA rules
• Case vignettes showing how real practices could be impacted
• Financial models for revenue at risk under new PA requirements
• A quarter-by-quarter roadmap to prepare for 2026
  
  

👉 [Download the Whitepaper]

Don’t let prior authorization reform catch you off guard. Start planning now.