Washington lawmakers advanced the most significant Medicare Advantage prior authorization reform in years this week. But as Congress moves to curb delays and denials for beneficiaries enrolled in private Medicare plans, CMS is simultaneously expanding prior authorization in traditional Medicare through a new model targeting many spine, orthopedic and pain procedures.
On July 21, the House Committee on Energy and Commerce passed the Improving Seniors’ Timely Access to Care Act in a 45-0 vote, clearing it for consideration by the full House.
The bill would require Medicare Advantage plans to respond to standard prior authorization requests within seven days and urgent requests within 72 hours. It would also move the process toward a real-time electronic system and require plans to publicly report denial data.
Among its most vocal supporters are the nation’s neurosurgery societies, and their case is clinical.
The American Association of Neurological Surgeons and Congress of Neurological Surgeons applauded the vote. Alexander Khalessi, MD, chair of the organizations’ Washington Committee, said that for patients with neurologic disease, a delay can mean the difference between “preserving function and living with permanent disability.”
The legislation cleared another panel days earlier. The House Committee on Ways and Means passed it 42-0 on July 15, adopting a substitute amendment that delayed its effective date by one year, to Jan. 1, 2029. The bill has nearly 300 House cosponsors.
For spine, orthopedic and pain leaders, however, the tension extends beyond a fight over private health plans. As Congress works to loosen prior authorization in Medicare Advantage, CMS is tightening it in the part of Medicare that historically operated without it, and targeting many of their procedures.
The government’s version, aimed at spine and orthopedic care
The Wasteful and Inappropriate Service Reduction model, or WISeR, introduced prior authorization to fee-for-service Medicare at scale for the first time.
The model launched Jan. 1, 2026, in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington and will run through the end of 2031. An algorithm screens each request, but a licensed clinician must sign every denial. CMS has emphasized that clinicians, not algorithms, retain final authority.
The incentive structure has drawn scrutiny. Contractors conducting the reviews receive a share of the “averted expenditures,” meaning their compensation is tied to spending they prevent Medicare from paying.
The list of services reads largely like a spine and pain roster. Procedures under review include epidural steroid injections, electrical nerve stimulator implants, percutaneous vertebral augmentation, image-guided lumbar decompression and cervical fusion, along with knee arthroscopy for osteoarthritis and skin substitutes. CMS delayed adding deep brain stimulation for Parkinson’s disease to the initial rollout.
Some surgeons in the participating states have been outspoken about the model.
Grant Booher, MD, of Longhorn Brain & Spine in Fort Worth, Texas, told Becker’s that the change means CMS “continues to make it harder for physicians to deliver timely, evidence-based care.”
Not every clinician objects. Some argue that a subset of the targeted procedures has been overused and warrants greater oversight.
The financial stakes are substantial. WISeR-covered services accounted for 5.3%, or $12.3 billion, of all Part B spending in traditional Medicare in 2024, up from 1.1% in 2019, according to KFF.
CMS is moving these cases to ASCs while screening them
Spine and orthopedic ASC operators should pay close attention to the timing.
During the same 2026 rulemaking cycle, CMS added 573 codes to the ASC Covered Procedures List, a major expansion for spine and cardiovascular care, and began phasing out the Medicare inpatient-only list. The agency is actively moving more spine and orthopedic volume into outpatient settings.
It then layered WISeR onto that shift. Traditional Medicare, long free of prior authorization, is now testing it on many of the same procedures orthopedic ASCs are being encouraged to perform. For spine and pain practices, WISeR is not arriving in isolation. It is landing alongside Ambulatory Specialty Model risk and the NOPAIN Act’s nonopioid payment changes, three CMS policies converging on the same income statement.
The administrative burden is already rising. Prior authorization affected as many as 46% of ASC cases in 2024, up from 42% in 2023, and industry leaders say the uncertainty is beginning to influence whether they launch new service lines at all.
Why healthcare executives should connect the two
Strip away the program names, and both developments center on the same question: Who gets to say no, and how are they paid to do it?
The Medicare Advantage bill represents Congress’ attempt to limit delays and denials in the private program. WISeR represents CMS bringing one of the private program’s defining tools, algorithm-screened prior authorization, into fee-for-service Medicare and directing it toward spine, orthopedic and pain procedures.
The compensation structure invites the same scrutiny Congress is applying to Medicare Advantage plans.
That case against private insurers intensified this month when Sens. Richard Blumenthal, D-Conn., and Josh Hawley, R-Mo., demanded records from UnitedHealthcare, Humana and CVS Health concerning their use of AI in coverage denials. The concern is that predictive technology, combined with a financial incentive to reduce spending, creates pressure to deny care.
WISeR incorporates such an incentive by design: The more spending a contractor averts, the more it can earn. For spine and orthopedic groups in the six participating states, the timing compounds the frustration. Even if the Medicare Advantage bill becomes law, its requirements would not take effect until 2029, and they would not apply to WISeR.
The potential relief is limited to private plans and remains years away. The new friction in traditional Medicare is already here, targeting procedures the same agency is encouraging physicians to move into ASCs.
Congress has recognized the contradiction, though unevenly. The House Appropriations Committee voted to block WISeR funding in its fiscal 2027 bill, 31 House Democrats pressed CMS to release denial data, and senators voted 46-50 along party lines on July 16 to reject a resolution seeking to repeal the model.
The bipartisan appetite to reform Medicare Advantage prior authorization has not yet extended to the government’s own model.
What to watch
The Improving Seniors’ Timely Access to Care Act still needs a House floor vote, and its sponsors are seeking action before the August recess.
Spine and orthopedic leaders in WISeR states have a more immediate marker. CMS has said it will pilot a “gold carding” exemption by mid-2026 that could spare clinicians with high approval rates from repeated prior authorization requirements, a potentially meaningful carve-out for high-volume surgeons with low denial rates.
The larger question is whether lawmakers will eventually hold CMS’ own model to the standard they are writing for private insurers.
For now, the practices moving Medicare cases into outpatient settings are absorbing both policies at once.
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