📍 Why This Checklist Matters

If you’re not in one of the six WISeR pilot states (New Jersey, Ohio, Oklahoma, Texas, Arizona, Washington), you might be tempted to sit back and watch how the Medicare Prior Authorization (PA) pilot plays out.

But that would be a mistake.

Here’s the truth:
➡️ This is not just a policy test.
➡️ It’s the beginning of a larger transformation in how Medicare reimburses outpatient care.

Even if you’re not directly impacted in 2026, you need to prepare now — because when it expands (and it likely will), the providers who planned ahead will avoid cash flow disruption, operational chaos, and patient delays.

Let’s help you become one of them.

✅ The Medicare Prior Authorization Readiness Checklist
(For Non-WISeR States and Forward-Thinking Practices)

🔎 1. Understand Which Services Are Likely Targets

CMS has already listed 17 outpatient services in the WISeR model as requiring prior authorization. These services are common, expensive, and prone to fraud or overuse.

Likely Categories Include:
– Neurostimulator implants
– Power wheelchairs
– Skin/tissue grafts
– Knee arthroscopies
– High-cost DME
– Complex wound care

🛠️ What to do now:
– Run a report of your top 50 CPT codes by volume and revenue.
– Highlight any matching or related services.
– Flag these procedures in your EHR/PM system with alerts.

👥 2. Assemble or Designate a PA Response Team

Most practices fail because no one owns the prior auth process. It’s spread thin across front office staff, billers, and nurses — leading to inconsistent follow-up and denials.

🛠️ What to do now:
– Assign 1–2 people to own Medicare PA.
– Create a dedicated prior auth email, Slack channel, or Trello board.
– Build a draft SOP: “If Medicare adds this CPT code to PA next quarter, here’s how we respond.”

🖥️ 3. Evaluate Your Technology Infrastructure

Will your software be ready if CMS expands prior auth?

EHR and PM systems vary in how well they:
– Identify services needing PA
– Track request/approval status
– Integrate with clearinghouses and APIs

🛠️ What to do now:
– Ask your vendor: “Do you support prior auth tracking and alerts?”
– Build a manual tracking sheet (Excel/Google Sheet) for trial runs.
– Tag patients whose visits include high-risk services.

📄 4. Create Standard Documentation Templates

The most common reason for a PA denial? Incomplete or vague documentation.

Every request must include:
– Diagnosis
– Clinical justification
– Failed conservative treatments
– Provider notes
– Prior test results or imaging

🛠️ What to do now:
– Draft a documentation checklist by service type.
– Create templated narratives for common procedures.
– Train providers: “Document like you’re submitting a pre-authorization — even when you’re not (yet).”

⏱️ 5. Simulate a Medicare PA Request

Run a “mock prior auth” on one service per week. You’ll quickly discover:

– Documentation gaps
– Staff knowledge gaps
– Timeline weaknesses
– Communication breakdowns

🛠️ What to do now:
– Choose a high-volume CPT code and walk through a full PA process.
– Use your real team, real software, and real documentation.
– Time how long it takes and where bottlenecks occur.

📊 6. Track Your Current PA Metrics

If you handle commercial or Medicare Advantage PA, that’s your goldmine of data.

Key Metrics:
– Average turnaround time?
– Approval rate?
– Appeal win rate?
– Volume of rework due to missing info?

🛠️ What to do now:
– Set a baseline PA performance dashboard.
– Use it to monitor readiness and justify investments.

🔐 7. Protect Your Revenue: Build an Appeals Process

Even with great documentation, denials happen. A well-crafted, timely appeal can recover thousands of dollars.

🛠️ What to do now:
– Create appeal letter templates with sample language.
– Designate staff to handle Medicare-specific appeals.
– Store appeal outcomes and monitor trends.

🧭 Bonus: Communication & Culture

PA success depends on team awareness. Your staff needs to:

– Know which services may need PA soon
– Understand who handles it
– Communicate with patients if delays are expected

🛠️ What to do now:
– Hold a team meeting: “Medicare PA is coming — here’s our plan.”
– Share this checklist.
– Ask: “What do you need to succeed if PA is added tomorrow?”

🧲 Why Confair Is the Partner You Need

At Confair, we work with medical groups, imaging centers, ASCs, and specialty clinics across the country. We know how to build PA systems that scale — not break when the rules change.

Here’s what we offer:
– Centralized PA team to handle all submissions
– Documentation coaching to reduce denials
– Appeals management with high overturn rates
– Real-time tracking dashboards
– Flexible integration with your EHR or workflow tools

You focus on care. We focus on compliance, cash flow, and clean approvals.

📣 Final Takeaway

You’re not in a WISeR state.
You’re not on CMS’s radar yet.
But if history teaches us anything — you will be.

💡 Getting PA-ready now costs time.
❌ Waiting until CMS mandates it costs revenue.