The Government has noted the savings that come with preauthoriation in Medicare Advantage and will be slowly rolling it out for regular Medicare. Preauthorization already exists in private plans. I spent two hours on the phone talking to idiots and another two weeks before I got the medication that I needed. Many patients give up and the insurance company adds it to their profits.

Lovely. Getting a pre-auth for employer sponsored insurance can be a royal pita, even when your continued existence depends on it, or when alternate choices are wrong in particular.

Well, crap! I start Medicare in a few months, and have been trying to find a creative way to keep my existing plan just so I can avoid the regular bs in Medicare.

Not needing preauthorization in regular Medicare was, until your post, part of my reasoning to not choose Advantage.

Fly-Sig:

Once you’re on Medicare that will become primary, your other plan will become secondary.

quote:

Originally posted by Sigmund:
Fly-Sig:

Once you’re on Medicare that will become primary, your other plan will become secondary.

Unless I'm mistaken or something has changed recently, that is reversed. I believe Medicare is always treated as secondary, and you don't get to "pick" that.

On the Advantage front, take a close look at what happens if you want to swap to regular Medicare down the road, especially as it relates to pre-existing conditions.

Everything I can find indicates that while the low premiums and extras may be attractive now, it can be a real shitshow to move out of those plans when they go up, network changes, the terminate them, etc.

quote:

Originally posted by Sigmund:
Fly-Sig:

Once you’re on Medicare that will become primary, your other plan will become secondary.

My job-provided healthcare is the primary. Medicare is secondary.

quote:

Originally posted by ZSMICHAEL:
The Government has noted the savings that come with preauthoriation in Medicare Advantage and will be slowly rolling it out for regular Medicare. Preauthorization already exists in private plans. I spent two hours on the phone talking to idiots and another two weeks before I got the medication that I needed. Many patients give up and the insurance company adds it to their profits.

Unless you can supply valid documentation that sounds like it's not valid.

quote:

Originally posted by ZSMICHAEL:

The Government has noted the savings that come with preauthoriation in Medicare Advantage and will be slowly rolling it out for regular Medicare.

authentication?

For those willing to do their own research, try "Is Preauthorization requirements coming to Medicare Part B?" as a search term.

quote:

Originally posted by Sigmund:
Fly-Sig:

Once you’re on Medicare that will become primary, your other plan will become secondary.

Yeah, I can't find a way out of Part A. If I had a job then I could get out of Part B, but that really doesn't solve the problem of being stuck within the whole Medicare ecosystem. We are getting absolutely screwed next year on IRMAA due to selling the family home, and my Christian Healthcare coverage today costs half of what Part B is going to cost me next year, and CHM is much better coverage than Medicare A and B (and supplementals, too).

The best advice I've heard about avoiding Medicare is to be wealthy enough to self-insure. But we didn't reach that level of wealth...

eta: We learned years ago of the benefit of being outside of the insurance system. Our CHM is not insurance but a cost-sharing which amounts to me filing the paperwork and getting a quick reimbursement. We choose our providers and make our own decisions without insurance authorization hassles. Providers give us a big discount for self-pay, a cost thus not incurred by insurers to pass on to us as higher premiums.

https://www.kiplinger.com/reti...anges-coming-in-2026
Number 6 for V tail

While I hate the idea of pre-authorization, I think this falls under "why we can't have nice things." It's because of the abuse of easy money to be picked up by charlatans.

The last PA I had was delayed because the Doctors office didn't send it correctly, took me researching it with UHC, they'd say it wasn't there, the DR blamed the insurance company immediately and each time I called.

Result, Dr office wasn't sending in the correct information and it wasn't going to the carrier for approval. Once I found out what the issue was, they sent the PA and it instantly came back approved, I was on the phone with her and she said "oh my it's already back approved"

Wife works for a major insurance agency, head of the HC service department, she said that 99% of the time they find the PA issue, or any claim denial is the doctor not submitting it properly, which was the case with my PA.

PA's do serve to monitor claims submissions and check if the request is valid, not every in many years have I ever had a PA denied, and we have UHC which is of course one of the companies under fire and the CEO murdered.

Medicare/Medicaid fraud is rampant, we've all seen the reports, I'd imagine its being implemented as a method of catching fraudulent submissions more than restricting valid medical requests. And you won't see a PA required for your Metformin and similar basic lower cost medications, it's going to be for high cost medications and procedures, to insure what's ordered is correct.

In a perfect world all Doctors and Medical companies would be honest, and bill properly, they wouldn't have to worry about putting in additional testing to help protect them from malpractice lawsuits, but that's not reality

I have had plenty denied. There is no universal form and often it is a moron{never a physician} that reviews it. It is just another stall tactic to avoid payment. After a number of weeks it becomes a physician to physician deal. If you are a gynecologist you may end up talking to a retired opthalmalogist.
There are much better ways to control costs than denial of care through preauthorization.

Medicare is not always primary, I posted incorrect info.

https://www.medicarefaq.com/fa...is-medicare-primary/

We have Medicare and Tricare For Life, for us Medicare is primary, for other situations it’s not that simple.

quote:

Originally posted by HRK:

Medicare/Medicaid fraud is rampant, we've all seen the reports, I'd imagine its being implemented as a method of catching fraudulent submissions more than restricting valid medical requests.

Whether or not a treatment is valid is up to my doc and me, not someone at the insurance company. My doc examines me and uses his/her experience to come up with a treatment plan. The insurance company only sees words typed on a screen. If the insurance company, or Medicare in this case, do not cover a certain item for anybody then that is fine. But they are not in a position to know better than the doc and patient for items they do cover.

I don't see how pre-authorization catches fraud. Medicare sends statements to the patient for what was billed, and the patient would know whether or not they had a surgery, went for an MRI, or had other tests.

quote:

Originally posted by ZSMICHAEL:

https://www.kiplinger.com/reti...anges-coming-in-2026
Number 6 for V tail

The link that you refer to, indicates that this is a test program limited to six states (New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington). I believe that you are in Mississippi, so you should not be affected by this program.

Yep. The good thing about living here is that new stuff is tried somewhere else first. The problem is once Medicare tries something other insurance companies throughout the United States jump on the preauthorization bandwagon.

The Centers for Medicare & Medicaid Services (CMS) is implementing a new model, WISeR, to streamline prior authorization processes for certain Medicare services using AI and other technologies. This initiative, starting in 2026, aims to reduce fraud, waste, and abuse in traditional Medicare by leveraging technology to expedite reviews and identify potential issues, while still ensuring final coverage decisions are made by licensed clinicians.
Key aspects of the WISeR model:

Targeted services:
The model focuses on outpatient procedures with a history of overuse or potential for fraud, waste, and abuse, such as skin and tissue substitutes, nerve stimulators, and certain surgical procedures.

AI and technology:
CMS will contract with organizations that utilize AI and other technologies to support the prior authorization process, but clinicians will ultimately make the final coverage determinations.
Geographic regions:
The WISeR model will be tested in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington, within specific Medicare Administrative Contractor (MAC) jurisdictions.
Pre-payment review:
Providers can choose to submit prior authorization requests or have their claims undergo pre-payment review.
Potential for exemptions:
CMS may offer exemptions from WISeR review for providers with strong compliance records.
Cost savings and care improvements:
The model aims to reduce unnecessary or inappropriate care, lower spending in Original Medicare, and potentially improve patient care by streamlining the prior authorization process.

Potential benefits of using AI in prior authorization:

Faster processing:
AI can analyze large amounts of data quickly, potentially accelerating the prior authorization process and reducing delays in care.
Reduced administrative burden:
AI can automate tasks like data extraction and summary generation, freeing up clinicians' time.
Improved accuracy:
AI algorithms can identify potential issues and inconsistencies in claims, potentially reducing errors and denials.

Potential concerns about using AI in prior authorization:

Algorithmic bias:
AI models can perpetuate existing biases in healthcare data, potentially leading to unfair or discriminatory outcomes.

Over-reliance on technology:
There's a risk that clinicians may become too reliant on AI and lose sight of individual patient needs and circumstances.
Increased denials:
Some physicians worry that AI could be used to increase prior authorization denials, even when care is medically necessary.
Lack of transparency and oversight:
There's a need for greater transparency and oversight of how AI is used in prior authorization to ensure accountability and prevent potential harm, according to Health Affairs.
Potential for delayed or denied care:
Some argue that prior authorization, even when streamlined by AI, can still delay or deny necessary care, according to the American Medical Association.

Here is a link to another article that has some more information.
https://www.statnews.com/2025/...enter-wiser-project/