Getting Ahead of the January 2026 CMS Prior Authorization Rule - Smart RCM and Payer Strategy

Starting January 2026, payers will be required to adopt FHIR-based API workflows, shorter turnaround times (standard in 7 days, expedited in 72 hours), and greater transparency in prior authorization.

• Understand the core requirements of the CMS 2026 prior-authorization rule and downstream impact for providers.
• Map changes into hospital RCM workflows: intake, documentation, approval turnaround, tech stack.
• Develop an action plan (people, process, tech) to mitigate the risk of delays, denials, and revenue impact.
• Key Value Proposition: Ensures your hospital isn’t caught off-guard by the new prior authorization regime — readies your RCM workflows for an impending shift with direct revenue risk.

The Wasteful & Inappropriate Service Reduction (WISeR) model is a pilot program that introduces prior authorization for certain services under traditional (Original) Medicare in six states, effective January 1, 2026. The program will run through December 31, 2031.

The program's intent focuses on the reduction of fraud, waste & abuse in federal healthcare spending & preventing payment for services that are low-value or not medically necessary. This is a mandatory pilot program applicable to six states, including Arizona, New Jersey, Ohio, Oklahoma, Texas & Washington. This webinar will review the types of outpatient procedures & items considered at risk for overuse or fraud that will require authorization.  Included will be documentation requirements and how to appeal denied claims. Ensure you and your staff understand the expectations and implementations needed to protect your revenue.

• Physicians
• Mid-level providers
• Coders
• Billers
• Revenue cycle staff
• Risk Management
• Nurses
• Denial management
• Practice managers
• Appeals staff