InSights 

Be WISeR: Expect CMS to Increase Prior Authorizations

Through its Wasteful and Inappropriate Service Reduction (WISeR) model, this newly announced initiative by CMS is aimed at reducing what it says is expensive, unnecessary care as covered by original Medicare. It’s designed to protect federal taxpayer dollars. According to CMS, “wasteful care” includes services provided to patients that yield no clinical benefit which can also put patients at risk for unnecessary procedures.

Per CMS, waste in healthcare represents as much as a quarter of healthcare spending in the US. The Medicare Payment Advisory Commission estimated that close to $6 billion in Medicare spending in 2022 was spent on services that provided minimal benefits.

Examples that have been identified by CMS as being particularly vulnerable to fraud, waste, abuse, or inappropriate use include, but are not limited to, skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy for knee osteoarthritis. The model excludes inpatient-only services, emergency services, and services that would pose a substantial risk to patients if significantly delayed.

While AI will play a major role, CMS points out that decisions will be driven by licensed providers, not technology. Incentives will be paid to providers based on performance while respecting the goals of reducing spending.

Click here for the CMS press release on WISeR, a full description of the initiative’s details, and links to additional information and fact sheets.

(It appears that prior authorizations [PAs] won’t only not go away, but they’ll become even more burdensome. ADSRCM supports an AI-driven automated PA option to help you combat what appears to be an ominously looming increase in PAs. ADS has the option as well if in-house automation is preferred!)

Saying “Goodbye” to Fee-for-Service Medicare?

Billy Joel has “Say Goodbye to Hollywood,” but many physicians are singing a variation: “Say Goodbye to Fee-for Service Medicare.” Here’s the explanation:

According to a JAMA Health Forum survey, the number of physicians shunning Medicare fee-for-service (or “traditional” Medicare), is increasing. Exits were based on providers who did not submit Medicare fee-for-service claims for 12 consecutive months.

In the report, all Medicare Part B claims submitted by 790,000 providers were analyzed. Results showed that those claims, from 2010 to 2024, dropped year by year, typically ranging from 1.8% to 3.6%. The study showed that primary care providers were more apt to exit (4.41%), followed by hospital-based specialists (3.5%), then by surgical specialists (2.99%), and then medical specialists (2.49%).

The pandemic was likely an exit factor after 2021. However, other factors, such as increased portal messaging and documentation requirements, and a recent reduction in Part B reimbursements, may also have contributed. However, there is a proposed 2.5% rate hike in 2026’s MPFS.

Click here for the JAMA study and complete details.

(Whether you’re still in Medicare fee-for-service or not, you’ll want all your HCFA/UB/WC/NF claims submitted cleanly with a nearly 100% success rate on first attempt clearinghouse submissions. We support that effort; ADSRCM will guarantee to increase your revenue in 90 days!)

Ambulatory Surgery Center Medicare Reimbursements to Increase?

The answer may well be “yes,” and by 2.4% under the proposed Medicare Physician Fee Schedule (MPFS) rule. CMS has estimated that payment and other updates proposed will save approximately $11 billion over the next ten years. Outpatient hospital services (OPPS) are slated to increase as well.

For 2026, CMS would shift 271 codes from the ASC Covered Procedures List after deleting them from the inpatient-only list.

Click here for full details from CMS.

(If you’re an ASC stakeholder, you’ll always want to ensure optimized reimbursements. ADSRCM’s outsourced billing/staffing services support that. If in-house automation is preferred, the MedicsPremier platform from ADS will help you do the same!)

Uncompensated Care to Rise by an Estimated $283 Billion

It’s good that Medicare reimbursements would generally increase in 2026; an example involves ASCs, as mentioned above.

But according to a report by the Urban Institute for the Robert Wood Johnson Foundation, an estimated $283 billion in uncompensated care will be sought from this year through 2034 by patients who have no insurance.

Hospitals will bear the brunt, with an estimated $85 billion to be expended on uninsured patients. Physicians will see $34 billion in services for uninsureds. The difference would include pharmacy/prescription medications at $56 billion. A category called “Other Services” would account for $108 billion.

Perhaps unsurprisingly, the states expected to be most affected are those that are among the most populated: CA, TX, NY, and FL.

Click here for the full Robert Wood Johnson report.

(Are your uninsured patients truly uninsured? Our highly accurate insurance discovery option helps you identify patients who actually have coverage and understand what it entails. And then, several AI-driven tools are supported to help you protect revenue in advance, including eligibility verifications, out-of-network alerts, an automated prior authorizations option, access to our patient responsibility estimator, and proactive denial alerts.)