The prior authorization landscape is shifting fast. Lawmakers are pushing to halt a new Medicare pilot, states are passing PA reform, and major BCBS plans are restructuring their authorization processes. For dermatology practices already dealing with 51% denial rates on biologics requiring prior auth, these changes could significantly impact your revenue cycle.
The WISER Pilot: What It Is and Why Lawmakers Want to Stop It
CMS launched the Wasteful and Inappropriate Service Reduction (WISER) model, a Medicare prior authorization pilot currently active in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. Six vendors have been selected to administer the program: Cohere Health, Genzeon Corp., Humata Health, Innovaccer, Virtix Health, and Zyter.
Six Democratic House representatives introduced legislation to halt the pilot, arguing it creates unnecessary barriers to patient care. The American Hospital Association has urged CMS to delay the WISER pilot by at least six months.
If your practice is in one of the six WISER states and performs skin substitute applications, you’re already subject to this prior auth requirement. If the pilot expands, more states and procedure categories could be affected.
BCBS Plans Changing Prior Auth Processes
Blue Cross Blue Shield of Alabama, in partnership with the Medical Association of the State of Alabama, has reached agreed-upon changes to their prior authorization processes. While details are still emerging, this signals a broader industry trend toward PA reform driven by provider pushback.
California’s 90% Rule
Governor Gavin Newsom signed legislation allowing California’s Department of Managed Health Care to waive prior authorizations for services that payers approve at least 90% of the time. This is a significant precedent — if a payer approves a procedure 9 out of 10 times, why require authorization at all?
For dermatology, this could eventually eliminate PA requirements for routine biopsies, destructions, and other high-approval-rate procedures in California. Other states may follow with similar legislation.
What Your Practice Should Do Now
- Check your WISER status — if you’re in AZ, NJ, OH, OK, TX, or WA, verify whether your procedures require WISER pre-authorization
- Track your PA approval rates — document which procedures have 90%+ approval rates to support advocacy for PA reform in your state
- Monitor BCBS updates — check your specific BCBS plan’s provider portal for PA policy changes
- Build a centralized PA tracker — log all authorizations, statuses, and expirations in one system
Key Takeaways
- The WISER Medicare PA pilot is active in 6 states with 6 designated vendors
- Lawmakers are pushing to halt or delay the pilot
- BCBS Alabama is reforming its PA process — watch for similar changes from your plans
- California now waives PAs for procedures approved 90%+ of the time
- Track your approval rates to support PA reform advocacy