Monday, March 23, 2026

CMS's WISeR model pilot now requires prior authorization for 17 outpatient procedures in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. The list includes deep brain stimulation, epidural steroid injections, cervical fusion, and knee arthroscopy. This is the first time traditional (fee-for-service) Medicare has used prior authorization — a tool previously limited to Medicare Advantage. The pilot runs through 2031. CMS will use results to decide whether to expand nationally.

IDR-related expenses reached $5 billion between 2022 and 2024. Providers submitted 1.2 million disputes in the first half of 2025 — up 40% from the prior six months. Three provider groups initiated 44% of all cases. Providers won 83-88% of the time, receiving payouts averaging 4x the standard in-network rate. 20% of submissions were ineligible. STAT News op-ed calls for Congress to fix the process before it "bankrupts patients and employers."

MA plans must publish aggregate PA approval/denial metrics by March 31. CMS killed service-level reporting — plans only disclose contract-level aggregates, not which specific procedures get denied most. Eight metrics required, but the most useful data (service-level denial patterns) was stripped from the final rule. First reporting cycle.

PIRG's "Outpatient Outrage 2026" report: hospitals charge $50 to $1,000+ in facility fees for routine doctor visits at off-campus clinics they've acquired. No added benefit to patients. 50% of community practices are now hospital-owned, making these fees unavoidable for millions. Only 21 states have any protections. Most patients find out about the fee after they've arrived, undressed, and can't leave.

New development: UHC's denial rate dropped from 34.2% to 19.1% across 6.4 million claims after the January 2026 congressional hearings. CEO Stephen Hemsley claimed the denial rate was "less than 2%" — a figure disputed by independent researchers and lawmakers citing KFF data showing UHC tied for the highest marketplace denial rate at roughly one-third of in-network claims. Hemsley's total compensation: $60M in stock-based pay. Cigna CEO David Cordani: $23.2M (279x median employee).