Center for Medicare and Medicaid Innovation launches new prior-authorization model to target Medicare fraud

Under the government’s Wasteful and Inappropriate Service Reduction (WISeR) Model, the Center for Medicare and Medicaid Innovation (CMMI) will evaluate select medical procedures identified as being “vulnerable to fraud, waste, and abuse.” The list includes several orthopaedic procedures, such as kyphoplasty, spinal cord stimulation, cervical fusion, and arthroscopic debridement of the osteoarthritic knee. The WISeR Model excludes inpatient-only services, emergency services, and services that would pose a substantial risk to patients if delayed. The program will launch on Jan. 1, 2026, in six pilot states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington.

“CMMI has the broad ability to test new models in the administration of Medicare services,” said AAOS Advocacy Council Chair Adam Bruggeman, MD, MHA, FAAOS, FAOA. “In this case, the organization is examining why the government doesn’t have a more robust system for determining fraudulent treatments — procedures that don’t follow the already-determined requirements for performing those surgeries — similar to what private insurance companies use. The thought process is that prior authorization in health insurance is excessive, but maybe prior authorization for the Center for Medicare Services (CMS) is insufficient.”

The goal of this program is to create a more robust postoperative review or “clawback” mechanism within Medicare to protect taxpayer dollars.

“In essence, CMMI aims to adapt the same artificial intelligence and machine learning that private insurers use for prior authorization and apply this to the post-procedure claims review, or post care, of Medicare claim review,” Dr. Bruggeman explained. “CMMI is offering a voluntary process in which surgeons can essentially ask, ‘Can I determine if I’ll be reimbursed before I perform the procedure? If not, I’m willing to go through prior authorization.’”

Early conversations with lawmakers
The Advocacy Council has already taken an active role in ensuring that orthopaedic surgeons’ collective voices are heard. “Unfortunately, we were not [invited] to the table when discussions about this initiative began,” Dr. Bruggeman said. “We are now requesting the opportunity to revise and provide input, alongside other medical specialties that would be impacted.”

Dr. Bruggeman added that the rollout process also raised concerns among lawmakers. “On one of our recent visits to Capitol Hill, members of Congress told us they had not been notified about this program in advance, which is unusual, as CMMI typically alerts them.”

AAOS also met with Abe Sutton, CMMI director and deputy administrator for CMS, to discuss potential improvements and considerations. AAOS recommended implementing a “gold-carding” process, limiting scrutiny to doctors who are more likely to be fraudulent or not provide high-quality care, and exempting physicians with a strong record of compliance and appropriate patient care to automatically receive approval.

“We’ve also talked about making this binding,” Dr. Bruggeman added. “For example, if a surgeon is notified in advance that this is an appropriate procedure, they don’t want to have a clawback on the backside like the insurance companies do. While CMMI was very open to both of those considerations, we have not seen that language included, and given that this is due to start on Jan. 1, we are requesting the implementation date be pushed back to allow for all stakeholders to create innovative ideas to make this as painless as possible, while allowing the government to do what they believe is necessary.”

Member updates amid ongoing changes
If done correctly, the program could serve as a model to reform other prior authorizations in other insurance products. AAOS will keep members updated on the most recent changes and the newest ideas for all of AAOS’ orthopaedic advocacy efforts. Major changes and updates will be publicized through communications from the Office of Government Relations, AAOS Now articles, and Headline News Now. Additionally, there will be ongoing education opportunities (e.g., webinars) for members on how these changes may impact their practice. 

Jennifer Lefkowitz is a freelance writer with AAOS Now.