{"id":240599,"date":"2025-10-21T08:37:17","date_gmt":"2025-10-21T08:37:17","guid":{"rendered":"https:\/\/www.newsbeep.com\/us\/240599\/"},"modified":"2025-10-21T08:37:17","modified_gmt":"2025-10-21T08:37:17","slug":"texas-is-guinea-pig-in-test-of-how-prior-approvals-will-work-in-medicare","status":"publish","type":"post","link":"https:\/\/www.newsbeep.com\/us\/240599\/","title":{"rendered":"Texas is guinea pig in test of how \u2018prior approvals\u2019 will work in Medicare"},"content":{"rendered":"

From a reader: \u201cPlease report on the Medicare<\/a> issue. Who in Texas state government is coordinating with this Medicare pilot program?\u201d<\/p>\n

Our dear reader is smart to seek reporting by The Watchdog on \u201cthe Medicare issue.\u201d It\u2019s huge.<\/p>\n

Starting on Jan.1, 2026, Texans on Medicare will suddenly be required to get prior approval<\/a> for 17 select medical services.<\/p>\n

Texas is one of six states in a pilot program<\/a> that\u2019s not too popular. Those in favor say prior approvals will cut down on fraud, and halt payment for some \u201cunnecessary\u201d surgeries. Estimates are that this could save billions of dollars.<\/p>\n

Watchdog Alert<\/p>\n

Are you a taxpayer in Texas? The Watchdog has your back.<\/p>\n

By signing up, you agree to our\u00a0Terms of Service<\/a>\u00a0and\u00a0Privacy Policy.<\/a><\/p>\n

Yet critics warn this will add another layer of bureaucracy for Texans seeking medical care. They also worry that the program is a process that will lead to privatizing traditional Medicare.<\/p>\n

Texas is a guinea pig in this test.<\/p>\n

Not state-run<\/p>\n

The reader asks who in state government is coordinating this. I learned the answer: no one.<\/p>\n

Texas Health and Human Services spokesperson Thomas Vasquez told The Watchdog: \u201cThis request is outside the scope of HHSC. Please contact the Centers for Medicare & Medicaid Services for information.\u201d<\/p>\n

For the test, third-party vendors will help administer the program. They will also use artificial intelligence software to help make approval decisions.<\/p>\n

The Centers for Medicare and Medicaid Services promises that humans, not software, will make the final approval decisions.<\/p>\n

Conflict of interest<\/p>\n

David Lipschutz, co-director of the Center for Medicare Advocacy<\/a>, told me his fear is that these outside vendors, who earn their money based on reported savings, will restrict care so they can make more money.<\/p>\n

\u201cPeople have a harder time accessing such care when these vendors are used,\u201d he said. \u201cThis would be taking some of the worst elements of Medicare Advantage and injecting it into traditional Medicare.\u201d<\/p>\n

List of 17<\/p>\n

Most of the 17 select treatments involve pain management. Some are: electrical nerve stimulators; deep brain stimulation for Parkinson\u2019s disease; some knee surgeries; epidural steroid injections; treatment for impotence, sleep apnea and spinal stenosis.<\/p>\n

The pilot program is slated to last six years.<\/p>\n

The actual name for the program is WISeR, which stands for Wasteful and Inappropriate Services Reduction.<\/p>\n

Federal officials say the program\u2019s goals are to improve patients\u2019 well-being, speed up the approvals, increase transparency of Medicare policy coverage and reduce medically unnecessary care.<\/p>\n

Doctors, through the American Medical Association, protest that doctors find pre-approvals that they often have to make to be \u201cburdensome and disruptive.\u201d<\/p>\n

If a patient completes the service without approval, the insurance company can deny payment.<\/p>\n

When he announced the program in June, Medicare administrator Dr. Mehmet Oz said he hoped to crush \u201cfraud, waste and abuse.\u201d<\/p>\n

Exempt from the test are services that are in-patient only and also emergencies. Also exempt, according to a government news release, are \u201cservices that would pose a substantial risk to patients if significantly delayed.\u201d<\/p>\n

Other states in the pilot program are Arizona, New Jersey, Ohio, Oklahoma and Washington.<\/p>\n

If the pilot proves successful, it could signal a significant shift in how Medicare operates \u2014 potentially replacing the traditional system that, in most cases, does not require prior authorization for procedures.<\/p>\n

The Medicare hotline is 800-252-9240. <\/p>\n","protected":false},"excerpt":{"rendered":"From a reader: \u201cPlease report on the Medicare issue. Who in Texas state government is coordinating with this…\n","protected":false},"author":2,"featured_media":240600,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[59],"tags":[3200,97,252,253,1022,132643],"class_list":{"0":"post-240599","1":"post","2":"type-post","3":"status-publish","4":"format-standard","5":"has-post-thumbnail","7":"category-health-care","8":"tag-commentary","9":"tag-health","10":"tag-health-care","11":"tag-healthcare","12":"tag-texas","13":"tag-watchdog"},"_links":{"self":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/posts\/240599","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/comments?post=240599"}],"version-history":[{"count":0,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/posts\/240599\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/media\/240600"}],"wp:attachment":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/media?parent=240599"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/categories?post=240599"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/tags?post=240599"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}