Kaiser Family Foundation Research released in August 2025 showed that one in four Medicare beneficiaries lived on less than $24,600 in income in 2024, and half lived on less than $43,200 [1]. Many have little or no savings, with 7.7 million enrollees spending more than 10% of their income on Medicare Part B premiums alone. For these financially fragile individuals, care delays or prior authorization denials are not minor bureaucratic inconveniences. They are threats to health and stability (KFF, 2024).
CMS, effective January 1, 2026, is piloting a new cost containment program for Original Fee-for-Service Medicare that, consistent with other recent Trump administration initiatives, aims to root out waste and abuse in government programs, including in Medicare. The new CMS initiative is called “Wasteful and Inappropriate Service Reduction” or “WISeR” program”. The WISeR program targets select medical services, with what CMS contends have “little to no clinical benefit” to now be subject to a technology-assisted prior authorization (PA). Procedures included in the WISeR PA program include services such as electrical nerve stimulators, certain spinal procedures and the rapidly growing use of skin and tissue substitute products [2], CMS emphasizes that implementing the WISeR policy does not change actual coverage rules, and that it relies on numerous NCDs and LCDs. While CMS has stated that coverage policy and rules will not change with the implementation of WISeR, it has incorporated into the contracts with organizations operating the prior authorization program, a compensation element that allows them to share in the savings generated from the WISeR program which may incentivize denials.
Meanwhile in the private sector, numerous leading Health Plans that operate Medicare Advantage programs, long criticized for heavy use of prior authorization and accused of resulting delays in receiving care or inappropriate denials for requested care, are moving to reduce their PA requirements. Twenty-nine insurers, including UnitedHealthcare, Aetna, Cigna, Humana, and major Blue plans, have pledged to streamline and reduce PA requirements (although not eliminate them.) This is a trend that ATTAC is seeing across the industry, as we have also assisted plans streamline and reduce the number of procedures in their PA programs in a similar manner.
In addition to general reductions in PA requirements the 29 plans have also promised to standardize electronic processes, and honor prior approvals as members may transition from one plan to the next. The consortium of plans has promised stated that rollouts of changes are planned in phases beginning in 2026 and continuing into 2027 (AHIP, 2025; Techtarget, 2025).
While coming from different starting points, the two pathways taken by CMS and separately by the private Plans illustrate a developing convergence in approaches. CMS is applying PA for the first time in fee-for-service to address to what it believes are procedures with very little health benefit that result in wasteful spending, while in the private market, Health Plans are actively reducing their PA lists to eliminate provider, patient and their own administrative burden and refocus on procedures where clinically driven PA has the greatest impact in reducing wasteful spending.
Prior Authorization and Potential Impact on Patient Outcomes
Various studies have cited evidence that suggests that how and on what procedures Prior Authorization is applied can have negative impacts on patient outcomes. In study published in 2022, The HHS Office of Inspector General (OIG) found certain instances of Medicare Advantage plans denying requests that met Medicare coverage rules, with many of these denials ultimately overturned on appeal [3]. The American Medical Association [4] reports that 93% of physicians say PA delays care, and about 80% report instances of treatment abandonment due to PA, and 29% report serious adverse events tied to PA (AMA, 2024; OIG, 2022). For populations with fewer economic resources, algorithmic PA compounds risk. A patient with $20,000 of annual income cannot easily wait weeks for an appeal or find workarounds. They are more likely to skip treatment entirely, leading to deterioration, late-stage diagnoses, or preventable hospitalization.
Prior Authorization and Financial Burden on Health Systems
Hospitals and physician groups often absorb significant costs from PA. The American Hospital Association [5] and Medical Group Management Association (MGMA) report rising denial rates and billions in administrative expense. The Council for Affordable Quality Healthcare (CAQH) finds PA is among the most time intensive transactions [6]. Even when denials are overturned, revenue cycles are delayed, accounts receivable expand, and patients often present later and sicker, raising uncompensated costs. Safety net systems are especially vulnerable (AHA, 2024; CAQH, 2024). Overly expansive PA programs can result in shifting costs from insurers onto providers and patients, which cannot be confused as creating efficiencies.
Population Health Implications
As Plans consider their Prior Authorization programs, certain potential population health impacts are important to consider:
- Exacerbated inequity. Low-income beneficiaries spend more of their income on health care and often lack the resources to navigate the complexities of modern healthcare. Overly expansive PA programs, especially for procedures with low denial rates, can have substantially greater impact on low-income enrollees.
- Clinical deterioration. Untimely determinations, and programs that subject all PAs to the same timelines can contribute to treatment abandonment and later-stage presentation, which translates into higher acuity admissions.
Impacts for Health Plans
- Conduct a Prior Authorization Program Review. If you haven’t examined the clinical efficacy, ROI, and administrative costs of your PA program in a few years, now may be the time. ATTAC can assist you with the program review for your Plan.
- Evaluate Turnaround Times. Consider whether certain procedures and services should have shorter “standard” turnaround times than others in your PA program to assure that necessary care is delivered timely.
- Continue preparing for electronic prior authorization requirements. The 2024 CMS Interoperability and Prior Authorization Final Rule still mandates API connectivity and public reporting. But implementing the interface shouldn’t be the end of Plan’s efforts. Plans can develop clinical decision trees for high volume procedure that can be automated to reduce overhead. Plans should review their PA systems to explore automation capabilities.
Impacts for Providers and Health Systems
- Build a prior authorization equity dashboard. Track approvals, denials, and overturns by payer, service line, and patient demographics. Monitor outcomes such as ED visits and admissions after denials to identify disparities and facilitate earlier interventions.
- Standardize documentation for high-risk services. Develop evidence packets that prepopulate diagnostic criteria and prior therapy data. Embed these into order entry to reduce the type of variance that leads to unnecessary denials.
- Create a rapid appeals team. Form cross functional teams of physicians, nurses, coders, and revenue cycle experts to resolve urgent denials within 72 hours. This protects patients and preserves revenue.
- Connect denials to patient navigation. When a denial occurs, outreach patients immediately, escalate for clinician review, and provide financial counseling. This reduces treatment abandonment and protects outcomes.
- Prepare for interoperability requirements. CMS’s 2024 rule requires electronic prior authorization APIs and public reporting. Providers and Health systems should examine their system’s ability to take advantage of these apis and submit electronically. Providers and also eventually map payer requirements, and incorporate those into their EMR platforms.
- Engage in policy. Push for transparency in PA criteria, public dashboards of denial rates, and prohibition of savings-based remuneration models for contractors. If MA plans are retreating from PA, CMS should take notice.
At ATTAC Consulting Group, we partner with health plans and providers to navigate complex regulatory requirements while keeping patient outcomes at the center. Our experts help organizations adapt to streamline operations and strengthen oversight. By combining policy expertise with practical solutions, ATTAC supports Clients in reducing administrative burden, protecting revenue, and ensuring members receive the care and benefits they deserve.
by Charles Baker, VP Compliance Solutions
[1] Income and Assets of Medicare Beneficiaries in 2024, Kaiser Family Foundation, August 25, 2025 [2] Wasteful and Inappropriate Service Reduction (WISeR) Model Office Hour, The Centers for Medicare and Medicaid Services, July 17, 2025, Page 12 [3] Some Medicare Advantage Organization Denials of Prior Authorization Requests, HHS Office of Inspector General. (2022) [4] Prior Authorization Physician Survey, American Medical Association. (2024) [5] Skyrocketing Hospital Administrative Costs, American Hospital Association. (2024) [6] Index Report, CAQH. (2024)
