Medicare Prior Authorization WISeR Program 2026 Guide

For years, we have watched as private insurers expanded prior authorization requirements, adding layers of administrative burden that slow care delivery and strain laboratory resources. Now, that same approach is coming to traditional Medicare. Starting January 1, 2026, the Centers for Medicare & Medicaid Services (CMS) will launch a six-year pilot program that brings prior authorization to fee-for-service Medicare for the first time in select states.

The Wasteful and Inappropriate Service Reduction (WISeR) initiative will require prior authorization for certain medical services in six states: Arizona, Washington, New Jersey, Texas, Ohio, and Oklahoma. While the program does not directly target laboratory testing in its initial phase, the administrative infrastructure and workflow changes it introduces will have ripple effects throughout the healthcare system. Laboratories in these states need to understand what is coming and how to prepare.

Understanding the WISeR Program

The WISeR program represents CMS's attempt to reduce what it considers wasteful or inappropriate services in traditional Medicare. Unlike Medicare Advantage plans, which have long used prior authorization as a cost control mechanism, traditional fee-for-service Medicare has historically operated on a simpler model: if a service is medically necessary and covered, it gets paid. The WISeR pilot changes that fundamental premise.

The program will initially focus on specific high-cost procedures, including epidural steroid injections for pain management and cervical fusion surgeries. Deep brain stimulation for Parkinson's disease was originally included but has been delayed for reevaluation. CMS released an operational guide for providers on October 10, 2025, outlining the steps that affected providers will need to follow to obtain authorization for covered services.

The Controversy and Opposition

The WISeR program has faced significant pushback from multiple stakeholders. The American Hospital Association (AHA) has been particularly vocal, sending a letter to CMS on October 23 requesting at least a six-month delay. The AHA's concerns center on the rapid implementation timeline and the lack of clear guardrails for the use of artificial intelligence in the authorization process. The organization has also raised questions about the vendor payment methodology and whether the incentive structure could lead to inappropriate denials.

House Democrats have been equally critical, with particular concern about the use of AI to expedite prior authorization decisions. Representative Lois Frankel captured the sentiment of many when she said, "Let's not bring this nightmare to Medicare, the one program that seniors still count on for guaranteed straightforward care." The House Appropriations Committee has advanced a 2026 spending bill that includes an amendment blocking funding for the pilot program, though the ultimate fate of that amendment remains uncertain.

Impact on Laboratory Operations

While laboratory testing is not the primary focus of the WISeR pilot, labs should not assume they will be unaffected. Prior authorization programs create systemic changes in how healthcare is delivered, and those changes inevitably impact laboratories. When physicians must obtain authorization for procedures, testing orders can be delayed or modified. When hospitals implement new authorization workflows, laboratories must adapt their processes to align with those changes.

More importantly, the WISeR pilot represents a test case for broader expansion of prior authorization in traditional Medicare. If CMS deems the program successful, there is no reason to believe it will not expand to include laboratory testing in future phases. We have seen this pattern play out repeatedly in the private insurance market, where prior authorization programs that start with high-cost procedures gradually expand to encompass an ever-widening range of services.

What This Means for Your Laboratory

If your laboratory operates in or serves patients from Arizona, Washington, New Jersey, Texas, Ohio, or Oklahoma, you need to start preparing now. This means understanding the authorization requirements for the procedures that are included in the pilot and ensuring that your ordering physicians are aware of the new requirements. It also means reviewing your current workflows to identify potential bottlenecks that could be exacerbated by authorization delays.

Beyond the immediate operational concerns, this is a moment to think strategically about how your laboratory handles administrative complexity. The trend toward increased prior authorization is not going away. If anything, programs like WISeR suggest that the administrative burden on healthcare providers will continue to grow. Laboratories that invest in systems and processes to manage this complexity efficiently will be better positioned to compete in an increasingly challenging environment.

Action Steps for Laboratory Leaders

There are several concrete steps you can take to prepare for the WISeR program and the broader trend toward increased prior authorization. First, educate your team about the program and its potential impact on your operations. Make sure your client services staff understand which procedures are affected and can communicate effectively with ordering physicians about the new requirements.

Second, review your current authorization management processes. Do you have systems in place to track authorization requests, monitor approval timelines, and manage denials? If not, now is the time to invest in those capabilities. The laboratories that struggle most with prior authorization are those that treat it as an afterthought rather than a core operational function.

Third, engage with your state and national laboratory associations. The opposition to the WISeR program is not over, and laboratory voices need to be part of that conversation. Share your concerns with your elected representatives and make sure they understand how programs like this affect patient access to care and the financial viability of laboratory operations.

Looking Ahead

The WISeR program is scheduled to run through December 31, 2031, giving CMS six years to evaluate its effectiveness. That is a long time in healthcare policy terms, and much can change during that period. What seems certain, however, is that the trend toward increased utilization management in Medicare is not going away. The financial pressures on the Medicare program are real, and policymakers will continue to look for ways to control costs.

For laboratories, this means that operational efficiency and administrative capability will become increasingly important competitive differentiators. The labs that thrive in this environment will be those that can navigate complex authorization requirements while maintaining high-quality service and reasonable turnaround times. This is not just about surviving the WISeR pilot. It is about building the infrastructure and capabilities that will be necessary to succeed in the healthcare system of the future.