So… What Is Prior Authorization?

Think of prior authorization as a permission slip from Medicare. Before your doctor can move forward with certain procedures, like back surgery or an epidural, they have to get Medicare’s okay first. If Medicare doesn’t approve it, you could be on the hook for the full cost.

It’s a step that can help reduce unnecessary or risky treatments, but it also means more red tape and possible delays in getting care.

Question: Why Is Medicare Doing This?

According to Medicare, the WISeR model is all about:

• Cutting down on fraud and wasteful spending
• Protecting patients from unneeded or potentially harmful treatments
• Using tech and expert review teams to ensure high-quality, cost-effective care

They’re emphasizing that the goal isn’t to deny care, it’s to make sure the care provided is truly necessary.

Which Services Will Need Approval?

There are 17 outpatient services that will now require prior authorization. These include:

• Back and neck surgeries
• Knee and joint surgeries
• Certain pain treatments, like epidural injections
• Skin grafts and nerve stimulators

These procedures have been flagged by Medicare as being overused in some cases.

Got a Medigap Plan? Here’s What to Know

If you have a Medicare Supplement (Medigap) plan like Plan G or Plan N, these changes still affect you. Here’s how:

1. Medicare Has to Say Yes First: Medigap only helps cover your costs (like deductibles and copays) after Medicare approves the service. If Medicare says no, Medigap won’t pay.
2. It Might Take Longer to Get Care: Prior authorization can slow things down while your provider waits for Medicare to review and approve.
3. Less Freedom Than Before: Traditional Medicare has always been known for its flexibility. This change adds a layer of control, at least for these 17 services.
4. No Formal Appeal: If Medicare denies the request, your doctor can submit more info, but there’s no official appeals process in this pilot.

How Does This Compare to Medicare Advantage?

If this all sounds familiar, it’s because prior authorization is standard in Medicare Advantage plans. But there are a few key differences:

• Traditional Medicare is run by the government, while Medicare Advantage is managed by private insurance companies.
• Only 17 services are affected in this pilot for Traditional Medicare, Medicare Advantage often requires prior approval for a much wider range of services.

What’s Next?

For now, this is just a pilot program in six states. But if it works the way Medicare hopes, don’t be surprised if it expands to other states, or even more services.

Even if you don’t live in one of the pilot states, it’s a good idea to keep an eye on this. The changes may eventually impact you, too.

What Beneficiaries Can Do Right Now

• Talk to your doctor: Before scheduling any procedures, ask if prior authorization is required.
• Plan ahead: Some treatments may take longer to get approved.
• Stay informed: Keep tabs on updates from Medicare, especially if you travel or relocate.

The WISeR model is a significant shift for Traditional Medicare. For beneficiaries, especially those with Medigap, it may feel like an unwanted dose of bureaucracy. However, Medicare views it as a means to rein in waste and ensure that care is truly necessary. Either way, it’s a good reminder to stay proactive, ask questions, and stay informed, because this pilot might just be the start of bigger changes ahead.

Contact your Pinnacle Financial Services team member today at 800-772-6881 or sales@pfsinsurance.com to get more information on Medicare selling.

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