From Prior Auth Pilots to Courtroom Pushback

Beyond the Fine Print

August 2025 Edition

CMS Oversight on a Flat Budget

CMS is still trying to do more with less. The annual survey and certification budget hasn't changed since FY 2015—but provider growth and complaint investigations continue to rise.

To stretch resources, CMS will launch a fall study comparing Accrediting Organization (AO) surveys with State Survey outcomes. Federal surveyors will also accompany AO teams on select reaccreditations.

First step toward a hybrid oversight model when state survey capacity can't keep pace.

QIES & HCQIS Scheduled Downtime

CMS has posted September maintenance windows for QIES and HCQIS Atlassian. Plan reporting and submissions ahead to avoid disruption: https://qtso.cms.gov/system/files/qtso/HCQISAtlassQIES_MaintSched_0925.pdf

New HHS Healthcare Advisory Committee

HHS Secretary Robert F. Kennedy Jr. and CMS Administrator Dr. Mehmet Oz announced a federal Healthcare Advisory Committee to drive patient-centered reform across Medicare, Medicaid, CHIP, and the Marketplace.

Focus areas:

• Chronic disease prevention and management
• Cutting red tape to keep providers focused on care
• Real-time data for claims and quality
• Medicaid quality for vulnerable populations
• Medicare Advantage sustainability

Nominations due September 22, 2025 https://www.federalregister.gov/d/2025-16136

Prior Authorization Comes to Medicare

CMS will pilot the WISeR Model (Wasteful and Inappropriate Service Reduction) in January 2026 in six states, including Ohio.

Scope: "low-value" services like skin/tissue substitutes, knee arthroscopy, and electrical nerve stimulators. AI will help expedite prior authorization, but CMS stresses that clinicians, not machines, make the final calls.

Concerns:

• Added provider burden
• Patient care delays
• Rural hospitals hit hardest as Medicare cuts loom in 2026

Details + FAQ: https://achi.net/newsroom/cms-pilot-program-to-implement-prior-authorization-requirements-in-medicare/

Courts vs. CMS (This Week)

Two major rulings in the past week:

1. ACA Marketplace Rule Paused A Maryland federal judge blocked parts of the "Marketplace Integrity and Affordability Rule," citing risks of stripping coverage from 2M+ Americans—particularly low-income enrollees. https://www.reuters.com/legal/litigation/judge-pauses-portion-us-changes-aca-insurance-2025-08-22/

2. Medicare Advantage Broker Pay Cap Overturned A Texas judge vacated CMS's $100 cap on MA broker compensation. The ruling frees up broker incentives—likely pushing more dollars into marketing. CMS has until Oct. 17 to appeal. https://www.marketwatch.com/story/medicare-advantage-brokers-could-now-focus-more-on-making-money-and-on-commercials-than-on-your-healthcare-6842323e

Key Takeaway

Flat budgets. AOs stepping into oversight. Prior authorization expanding into traditional Medicare. A new federal advisory committee. And now courts are pushing back on CMS reforms.

Oversight, payment, and policy are shifting on multiple fronts. Facilities can't just track CMS memos; they will also need to monitor the courts and Congress.