On Jan. 1, 2026, the Center for Medicare and Medicaid Services(CMMS) will embark on a new paradigm that will affect New Jersey seniors choosing to remain on traditional Medicare Parts A and B, and the physicians who care for them, Known by the acronym WISeR (Wasteful and Inappropriate Service Reduction), it will mandate physicians to obtain pre-authorization for a number of commonly performed procedures before payment for them will be allowed. Prior authorization, common in so-called Medicare Advantage plans, has been extremely uncommon in traditional Medicare, until now. New Jersey is one of 6 States that has been chosen by CMMS to participate in this new initiative.
CMMS will contract with Artificial Intelligence companies, that will apply predictive analytics to make initial determinations re: the medical necessity of (initially) 17 procedures, and will share in savings accrued by denying care deemed wasteful or inappropriate. Some of these procedures, such as hernia repair, aortic valve replacement, and epidural steroid injections for spine pain, are quite common, performed thousands of times a year on patients of Medicare age. While ultimately final decisions will be made by humans, patient care will be delayed while requests are churned through algorithms. Care delayed can be care denied. Drs. will have to add another layer of bureaucracy to their already overburdened work lives, and the money to be saved by CMMS palls in comparison to the overpayments made to Medicare Advantage operators each year.
It has been estimated by studies performed through the Kaiser Family Foundation (KFF) that the Medicare Trust Fund expends between 22% and 39% more in overpayments to “Advantage” plans (over the cost of caring for patients on traditional Medicare) because of Advantage operator’s practices of favorable risk selection, and upcoding of patients’ medical records, to make people appear on paper to be sicker than they truly are. This overpayment amounts to between 35 and 80 billion dollars a year. WISeR at best would save a tenth of that. Last year, prior authorization was required for some 50 million procedures that were performed on Medicare Advantage enrollees. Of these, about 3 million (6.2%) were initially denied. Of those denied, only 11% were appealed, but of those that were appealed, more than 80% of the initial denials were overturned.
It is important to root out waste and fraud in any publicly funded expenditure, but the amounts to be saved with WISeR do not seem to justify the expense, burdens to caregivers, and delays in care that this program will inevitably cause.
Over 20 surgical specialty societies, the American College of Physicians, and the American Medical Association have all staunchly opposed this intrusion into the practice of medicine. Both New Jersey Senators, and several Congresspersons have signed on to a letter asking that WISeR not be implemented. It is time to add your voice.
Please ask your legislators to join the fight against WISeR, and consider writing directly to Dr. Mehemet Oz (the director of CMMS) and Abe Sutton (the associate director) at CMMS, 7500 Security Blvd, Baltimore, MD 21244, expressing your opposition. We must put a stop to WISeR before it becomes a fait accompli.
Lloyd H Alterman, MD, FACP
609 W South Orange Avenue, Apt. 6JK
South Orange, NJ 07079
(908) 868-0523