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Key Medicare benefits are being stripped away, and patient care is being handed over to profit-driven corporations.
On June 25, 2025, in an unprecedented move, Dr. Mehmet Oz and Robert F. Kennedy Jr., through the Centers for Medicare & Medicaid Services (CMS), announced that Original Medicare will now require prior authorization for a list of 17 services.
This marks a major shift—and a serious rollback of a key protection retirees have relied on for decades.
Original Medicare was designed to give patients access to medically necessary care without a for-profit company standing between them and their doctor. If your doctor said you needed it, you got the care. No Prior Authorization.
Now, for the first time, CMS is launching a pilot program that uses third-party contractors to use prior authorization to review and approve services. These companies are paid based on how much money they save, which often means denying or delaying care.
So far, CMS has announced 3 of the 17 targeted services:
The remaining 14 services have not yet been disclosed.
This mirrors the worst aspects of Medicare Advantage, where prior authorization is routinely used to block or delay care. One of the largest insurers, UnitedHealthcare, became infamous for their Prior Authorization strategy insiders described as:
“Deny. Delay. Defend.”
This isn’t the only rollback. The current administration also withdrew a proposal to allow Medicare to cover GLP‑1 weight-loss drugs like Ozempic, Wegovy, and Zepbound to treat obesity—a chronic condition that worsens health and drives up costs.
Covering these drugs could have improved health outcomes and reduced Medicare spending.
Together, these actions represent a troubling trend:
Key Medicare benefits are being stripped away, and patient care is being handed over to profit-driven corporations.
I share some of your concern regarding third party contractors. However it is very difficult for any government agent to deny a service to a voter in the next election. Some checkrein is needed to be certain that legitimate and necessary procedures can continue to be provided – and at a fair reimbursement rate. I fear the medicare rates for providers are already causing many younger physicians in training to opt out of specialties with a high geriatric population
Another article published on Healthcare Uncovered on this topic: https://healthcareuncovered.substack.com/p/cms-is-trying-to-expand-prior-authorization
Great article. Thank for posting
This article is full of Bias, Sensationalism, Lack of Nuance, Speculative Claims, and Incomplete Context, starting with the title!
It’s fear-mongering at its worst.
• Bias and Sensationalism: The article’s language (“stripped away,” “profit-driven corporations,” “vanished”) is alarmist, framing the WISeR Model as a betrayal rather than a pilot to address documented waste (e.g., $5.8 billion in 2022). It omits CMS’s rationale, such as fraud prevention and patient safety.
• Lack of Nuance: It doesn’t mention that WISeR is voluntary for providers (they can opt for prepayment review instead), excludes emergency services, or is limited to six states, which reduces the perceived scope of the change.
• Speculative Claims: The assertion that contractors will routinely deny care is speculative, as WISeR hasn’t started (January 2026). While the incentive structure raises concerns, the article assumes outcomes without evidence.
• Incomplete Context: It ignores potential benefits, like faster prior authorization via AI (CMS claims MA contractors achieve near-instant decisions for some services) or exemptions for compliant providers (90% approval threshold).
If you believe this I have a bridge for sale.
Some background information for the curious HD forum readers:
1) Arthroscopy for osteoarthritis is NOT recommended by the American Academy of Orthopaedics Surgeons, British Medical Journal after multiple decade studies showing ineffectiveness. CMS still pays, prior authorization is not required (but optional under selected regions) under traditional Medicare.
2) Nerve stimulation devices do not address underlying causes of pain, are ineffective in low back pain, and other chronic pain conditions. CMS still pays without prior authorization.
3) Congress created Medicare Part D covering drug prescriptions in 2003, but specifically prohibited weight loss drugs after the 1990’s sensational weight loss drug combo Fen-Phen was later found to cause heart valve damage and pulmonary hypertension (right side heart failure). Multiple attempts since then to lift this prohibition failed.
4) Another sensational drug was Vioxx (1999), marketed as pain medicine without stomach side effects. Traditional Medicare did not pay, so people signed up with Medicare Advantage to get it. Kaiser Medicare Advantage refused to cover it and petitioned the FDA to withdraw the drug due to increased stroke and heart attack. Merck withdrew Vioxx in 2004 after a long term study confirmed the increased risks and an estimate of 60,000 deaths.
👍 rational thought. You don’t want or need and can’t pay for everything.
Actually only partly rational. Not sure what Vioxx or Fen-Phen have to do with the proposed approval of GLP-1 weight loss drugs which have shown health benefits far beyond weight loss and sugar control.
Fen-Phen and Vioxx fiascos made Congress cautious about lifting the payment prohibition before long term studies are done, and of course politics. GLP-1 drugs are known to cause thyroid tumors in animals; hence they are prohibited by FDA for a group of susceptible patients. This class of drugs could be the new miracle drugs for many people, although they cost about $10 to $16 K a year for life. Medicare has been paying for gastric bypass surgery since 2006 (about $30 K one-time payment), after the procedure was proved to be effective since 1970s (yes, it took over 30 years of data).
Of course this trial could be the start of something dire, but those 3 services are among the most often flagged as abuse/fraud. They should be leading with rationales, however, so not a great rollout.
If they really want to save money then they should have left a structured GLP-1 tightly managed weight loss program to save the gobs of money spent on diseases associated with obesity.
I’ve often thought if they re-allocated the money spent on weight-loss drugs into providing education about how to achieve real, long-term weight-loss solutions (eat less, eat healthier, exercise daily), it would be a better way to spend the money.
While lifestyle choices are undoubtedly important, the scientific consensus is that genetics significantly influence an individual’s susceptibility to obesity. It’s not simply a matter of willpower for many people; their biology can make it more challenging to maintain a healthy weight.
I think food availability and (lack of) physical activity are the likely culprits. Look at photos from the early 1900’s. You are far more likely to see people who look malnourished than over-nourished. There was no high-fructose corn syrup in those days and people moved all day long.
What was true back then still holds true today. Expend more calories than you take in and you will lose weight. Expend fewer calories than you take in and you will gain weight.
So all the people with the “wrong” genetics moved to the US? More likely it’s how much Americans eat. There have been several recent articles on the difference between Italians and Americans when it comes to food and obesity. When I moved to the US I was amazed by the portion sizes and they’ve only grown since. Not to mention snacks and sugary sodas. Then there’s the prevalence of ultra-processed “food”.
If you want to disagree with science and you believe it’s just a matter of habit and willpower you’ll have to discuss with someone else. Yes, Americans are more careless with their eating habits, but while that contributes to being overweight, obesity is much more complicated and someone hundreds of pounds overweight can’t simply change habits for success even if they wanted to.
The Japanese have a term for eating until you are 80% full is hara hachi bun me (腹八分目). This phrase, often practiced in Okinawa, translates to “eight parts (out of ten) full”. It’s a Confucian-inspired concept that encourages mindful eating and portion control to promote a healthy weight and potentially increase longevity.
I try to utilize this theory, but find I stay hungry, and eat more 1- 1 1/2 hours later. I also perform heavy duty stationary biking for an hour, and weight train at least 6 days per week. All this effort including last year biking1,700 miles. My grandfather who I take after physically died before 70, and this motivated me to be committed to nearly daily exercise for the past nearly 50 years, but yet I still meet the criteria for obesity 😞. A large component has to be genetics.
If it were genetics just as many people would have been obese 50 years ago. They weren’t.
High fructose corn syrup was the worst thing to happen to food.
A handful of genes influence appetite, satiety, metabolism, fat storage, and energy expenditure. Population-based studies show that heritable traits vary by age, diet, exercise, environment, and population (from 25% to 80%).
Medicare covers gastric bypass surgery as durable effective weight loss and health benefits for people with BMI over 35.
“A major Medicare benefit just vanished” Really? But I looked and could not find any! The CMS Factsheet on Wasteful and Inappropriate Services Reduction Model (WISer) confirms that this is a 6-year pilot program in selected regions (Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington) with no change in coverage, payment or coding procedure for any of the 17 services. Participation in this pilot program is voluntary – any provider is free to ignore this program, although CMS routinely conducted medical reviews, and this time this review will be done by WISeR contractors’ AI program and licensed clinicians (called participants).
Anyone can say that prior authorization is synonymous with benefit denial, but it might be semantics with regards to Medicare programs whether denial is done early before services via preauthorization or done after services via CMS medical documentation review. The public has been shielded from the CMS preauthorization game: the rules are hidden; the players are rotating teams of coders from CMS government positions to private coding companies. Usually, CMS lost most games no matter what new rules or models are rolled out – most recent were CMS’s coordinated care and disease management demonstration project, Medicare Part D premium stabilization demonstration program.
One note of caution: CoPilot AI copied the headline and body of the OP to reply to my query as facts when I last checked. Nothing personal but then AI is not a person, and it needs to be taught for the benefit of the humans.
I think you’re being naive if you don’t think this will lead to people being denied care just so a for profit company can make money. If CMS wants to save money without reducing care they can hire doctors who are paid a salary regardless if they deny care. If in fact there is so much waste then the cost of these doctors will pay for themselves.
Managing several health plans and being on the boards of directors of three HMOs during my working years I am familiar with these arguments.
But you either manage health care costs or you don’t.
You try and assure care that is provided is necessary and appropriate or you employ higher deductibles and co-payments and co-insurance or simply don’t cover certain services.
In the absence of some combination of the above the growth in premiums simply reflects the cost and intensity of services provided. And then there are complaints about premiums.
Medicare already uses rules and limits on several services and pre authorization for some medical equipment. Medicare’s comparatively lack of oversight is why it has high rates of fraud and typically takes years to uncover it.
What do Americans want when it comes to receiving and paying for health care?
Whatever it is, It doesn’t seem realistic.
The devil will be in the details, don’t you think?
I’ve seen enough details to see the devil in it.
At 59, I am not Medicare eligible yet but for the last 7 years I had managed my parents care and there were times that even with traditional Medicare, there were limits on how often tests could be run and which medical equipment was deemed necessary. There has to always be some counterweight balance or eventually the system collapses if there is no push and pull.
Lucretia, thank you for this important info. I had heard nothing about it till your article.
I think this got lost because of the bill being voted on. I really didn’t see much press about this. My big issue is once again the current administration has inserted a for profit company into the approval process that are incentivized to deny care. The for profit companies are only paid if they deny care. I’m all for reducing fraud and waste in Medicare but this is putting the wrong incentives in place
If this is the case then either we should be able to get a rebate on our Federal premiums and/or allow traditional Medicare enrollees to consider enrolling in Medicare Advantage. This is a governmental bait and switch, as this is not what we signed up for!
As troubling as this is it is no where near the amount of prior authorizations that any Medicare advantage company uses. It’s just a troubling first step.
Two comments: 1) I could be wrong, but I believe one of the conditions of Medicare Advantage is that anyone can switch to it from original Medicare at any time without medical underwriting. But it’s a 1 way trip in most states as switching back requires medical underwriting. 2) I had the same initial reaction as you, but then it occurred to me that with original Medicare I can still go to any approved Medicare provider. Most Advantage plans require you to use their network. In my opinion picking my provider is still a huge benefit of original Medicare.
I agree. But this is the beginning of a slippery slope to insert a for profit company into original Medicare to deny care and make a profit.
I agree. I was simply clarifying a point that people can switch to a Medicare Advantage plan during annual enrollment. I wasn’t suggesting it’s a good idea. In fact, I’m confident the financial incentives surrounding this new program will encourage denials for legitimate requests. It’s well documented in the medicare insurance arena that a significant percentage of denials are never challenged. Easy money for companies focused on the bottom line.
During the first year you have a Medicare Advantage plan you can switch back to Original Medicare plus Medigap, without underwriting, but it’s a one time offer.
I agree that the ability to see any doctor, anywhere, is huge.
There are occasional exceptions: Last year just before open enrollment, I received a letter advising me that my Medicare Advantage plan was ending and that I could switch to another Medicare Advantage plan or to Original Medicare. I jumped at the chance to have Original Medicare. So far, so good.
I’m not saying I would sign up for an advantage plan, but people should get an opportunity to if they are not going to get the freedom of choice they’re paying for. Some might decide if this is where traditional Medicare is going they should have the option to switch to a plan that is less expensive if they’re not getting what they signed up for.
In our case as I have written before we signed up for a free five star advantage plan for the first year of Medicare eligibility so we could avoid a year of supplemental policies’ premiums while we were young and healthy, and to take “advantage” of the other perks. We switched to traditional before the end of the one year trial period so under current rules can not switch back.
“ so under current rules can not switch back.”
I don’t believe that’s true. Please provide the relevant reference.
Reading my comment, I said “at any time”. I meant and should have said “at any annual open enrollment” as Kathy correctly said below.
You can sign up for Medicare Advantage during the annual open enrollment period. It’s not clear to me whether you can be refused enrollment..
Any Medicare Advantage company will take you. These for profit companies are paid at least $1,000 a month by the federal government because you are giving up original medicare. If they can upcode you with additional diseases they get even more.
I hope I was clear. This is in no way an endorsement of Medicare Advantage which has hundreds of prior authorizations. I just wanted to alert people to what the current CMS is doing to our healthcare
What they are trying to do is make it affordable. The Part A trust is nearly depleted. I don’t agree with this administration on hardly anything, but this is necessary. What alternative do you see for managing costs?
Any Medicare advantage company is happy to take you because they are paid by the federal government at least $1000 a month for you. And if they can upcode you that you have more ailments then they get paid more. Medicare Advantage does not save the government money. We have been sold a bill of goods that putting a for profit company in the mix to deny you care saves the government money. It does not
Thanks for heads up. Wonder why I haven’t seen anything about this in mainstream media. One reason I pay a lot for Medigap to avoid these checks.
This is really bombshell stuff that has flown under the radar. Appealing claim denials likely will take a serious amount of time, especially for older Medicare patients who already have a limited life expectancy.
Thanks for bringing this up, now wondering what are the rest of the procedures that will require pre-authorization as you mentioned only three with fourteen to go.
pre certification/authorization of selected services most subject to abuse is logical and appropriate. It not only is better care, but also a way to control expensive.
Dr Oz is speaking out of both sides of his mouth. He has also asked Medicare Advantage companies to reduce the procedures that require prior authorization. Specifically the same knee surgery that he saying these for profit companies will use prior authorization https://www.latimes.com/business/story/2025-06-27/5-takeaways-from-health-insurers-new-pledge-to-improve-prior-authorization-united
Not when their compensation is a percentage of how much they deny. That sets up a powerful incentive to deny needed care.
Absolutely. I am all for reducing waste but the biggest waste of money is in Medicare advantage. United Healthcare is being investigated for sending nurses to Medicare patients home just so they can upcode them to get higher Medicare payments but not providing better care. That is pure evil.
One reason that I switched from Medicare Advantage to Original Medicare when I had a one-time chance to do so was exactly this: ridiculous and unnecessary “perks.” As a retired nurse in good health who fills my few prescriptions religiously, I got tired of being badgered with phone calls offering “help with managing your medications.” Also constant offers to avail myself of in-home health assessments, by a Nurse Practitioner no less. I took advantage of this once, merely to see if this was a job I might consider for myself. I decided that I couldn’t participate in such a wasteful endeavor. And then there were the unordered, unwanted boxes of unnecessary (and likely overpriced) medical supplies that would occasionally arrive. Just a way to justify their services. Makes me angry all over again just writing about it.
Not sure why this would make you angry, Linda. Yes, phone calls at inconvenient moments are monumentally frustrating, but I simply decline the services and withdraw authorization for the calls. I too had one of the silly in-home health assessments and told my MA plan (the much-despised UHC) that I would do so only on Zoom going forward. It has never happened. I get my required yearly assessment done by my PCP at my annual physical. He just sends in the form. Done.
If they are totally unethical perhaps, but what I read says there are checks. That’s the same argument against insurance companies which is not true.
keep in mind that even physicians estimate 25% of care provided is unnecessary.
What on earth makes you think people making mega-bucks off healthcare are ethical? You just pointed out that some people game the “no pre-approval” system. Now a few lucky people will be able to game it the other way.
They are doctors who make these decisions, they have to subvert their own integrity. There is no value to an insurer in denying necessary care.
Even in the private sector where there is a lot of criticism, people don’t realize that the majority of workers are in employer self insured plan and while an insurance company processes claim they have no financial stake in the payments.
what is the alternative, a blank check? That’s nearly what we now have now and then with it the complaining about higher deductibles and higher premiums.
you can’t manage health care costs without managing health care services or shifting more cost to patients.
Here is how the for profit company United Healrhcare is denying care to make a profit https://www.wsj.com/us-news/unitedhealth-medicare-fraud-investigation-df80667f?st=vkWRh5&reflink=article_copyURL_share
Thanks for the heads up. This is probably bad. As Charlie Munger said (something to the effect of) “tell me the incentives and I’ll tell you the results”. According to the CMS fact sheet these paid contractors will “…receive a percentage of the reduction in savings…”. Yeah, I’m sure medical wellbeing will drive their decisions. The exact phrase from the CMS fact sheet is: ” For each selected service, participants will receive a percentage of the reduction in savings that can be attributed to their reduction of wasteful or inappropriate care. Wasteful and Inappropriate Service Reduction (WISeR) Model Overview Factshet
Lucretia, you had me at This mirrors the worst aspects of Medicare Advantage.
Thanks for helping me to understand the forthcoming changes.