Why US Medical Billing Companies are Choosing Offshore Medical Billing in 2025?
02 Jan 2025
🕒 The Big Shift is Coming
Since its inception, traditional Medicare (Part B) has allowed providers to deliver care and bill later – Without needing prior approval for most services. But that’s about to change.
Starting January 1, 2026, the Centers for Medicare & Medicaid Services (CMS) is launching a pilot prior authorization program for traditional Medicare under the WISeR Model (Wasteful and Inappropriate Services Reduction). This will apply in six states:
New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington.
📋 Why This Change Matters
The pilot aims to:
Reduce unnecessary services.
Until now, prior authorization (PA) has mostly been the headache of commercial and MA payers. But in 2026, traditional Medicare will join the club — starting with select outpatient services.
⚠️ What Will Require Prior Authorization?
CMS has identified 17 outpatient procedures prone to overuse or fraud. These include:
Neurostimulator implantation
Knee arthroscopy
DME like power wheelchairs
Skin and tissue substitutes
Certain wound care supplies
🧠 Full list expected to be published in CMS documentation closer to Q4 2025.
These procedures, when performed in hospital outpatient departments (HOPDs), ambulatory surgical centers (ASCs), or similar facilities in pilot states, will require approval before rendering care.
🏥 Who Will Be Impacted?
✅ Providers in WISeR States (NJ, OH, OK, TX, AZ, WA):
❌ Providers Outside WISeR States:
🧮 What This Means for Your Revenue
Let’s be honest — prior authorization slows things down.
This pilot may seem limited, but it’s a policy shift that will likely expand in future years. That’s why smart providers — even outside the pilot states — are already preparing.
🔍 Why Is CMS Doing This?
CMS stated the goal is to “reduce wasteful and inappropriate care while preserving access to medically necessary services.”
But let’s be clear:
The real reason is cost control.
Between fraud, overuse, and inaccurate billing, Medicare loses billions each year. CMS wants to use prior auth as a filter — ensuring services are justified before dollars go out the door.
👀 What Should You Do Now?
Whether you’re in a WISeR state or not — the time to observe, learn, and prepare is now:
💼 Why This Isn’t Just a WISeR State Problem
Sure, the pilot is limited — but CMS is testing the waters. If it works, expect a nationwide rollout in 2–3 years. That means:
🔧 How Confair Helps You Stay Ahead
At Confair, we know how fast the rules change — and how slow practices often are to respond. That’s where we step in.
Here’s how we help:
🧲 Final Takeaway
This is not just a policy experiment. It’s a signal.
Medicare is no longer giving a free pass on high-cost services. Prior auth is coming — and your revenue depends on how well you adapt.
If you’re in a pilot state — call us today.
If you’re not — still call us. Because 2026 is just the beginning.