Aiming to smooth the transition for physicians impacted by a new Medicare prior authorization pilot, the Texas Medical Association is coordinating with Cohere Health, the entity responsible for processing the program’s requests in Texas.
This past July, the Centers for Medicare & Medicaid Services (CMS) announced its Wasteful and Inappropriate Service Reduction (WISeR) Model program, to be run in Texas and five other states from 2026 to 2030. The initiative aims “to expedite and improve the review process for a pre-selected set of services that are vulnerable to fraud, waste and abuse,” per the CMS website. The program is for traditional Medicare only; Medicare Advantage isn’t impacted by the initiative.
In November, CMS announced Cohere Health would be the technology vendor overseeing Texas’ WISeR reviews. TMA has since been in close communication with Cohere to gather crucial information for physicians.
“We can assure our physicians we’re there with them,” said TMA Executive Vice President/CEO Michael J. Darrouzet. “We can communicate on their behalf to Cohere and walk along with them in this implementation. We will put all the resources we have available to communicate, educate, and try to steer the process.”
For the WISeR services CMS identified, Texas physicians can opt for prior authorization through Cohere Health or through Novitas, the Medicare administrative contractor (MAC) overseeing Texas. If a physician does not request prior authorization for a service on the WISeR list, the claim will be subject to prepayment medical review. If a Texas physician does submit a prior auth request through Novitas, it will be routed to Cohere Health for initial review.
Services on the WISeR list include:
- Electrical nerve stimulators
- Sacral nerve stimulation for urinary incontinence
- Phrenetic nerve stimulators
- Vagus nerve stimulation
- Induced lesions of nerve tracts
- Epidural steroid injections for pain management excluding facet joint injections
- Percutaneous vertebral augmentation for vertebral compression fracture
- Cervical fusion
- Arthroscopic lavage and arthroscopic debridement for the osteoarthritic knee
- Hypoglossal nerve stimulation for obstructive sleep apnea
- Incontinence control devices
- Diagnosis and treatment of impotence
- Percutaneous image-guided lumbar decompression for spinal stenosis
- Skin and tissue substitutes
Based on Cohere Health’s assessment of the codes subject to review, specialties expected to be most impacted include:
- Anesthesia
- Emergency medicine
- Interventional radiology
- Neurology
- Neurosurgery
- Orthopedic surgery, including sports medicine and spine surgery
- Otolaryngology
- Pain medicine
- Physical medicine and rehabilitation
- Sleep medicine
- Urology
- Vascular surgery
- Wound care
For physicians providing care in these areas, “submitting through the Cohere process is actually going to be the best way for them,” Brian Covino, MD, Cohere Health’s chief medical officer, told Texas Medicine Today. “It'll be the easiest form of submission. It'll require the least number of handoffs between these entities, and [physicians] can [often] get answers back in seconds to minutes.”
Physicians wishing to familiarize themselves with WISeR prior to its launch can register to attend a Novitas-hosted webinar, featuring Cohere Health representatives, on Thursday, Dec. 18, at 9 am CT. Novitas and Cohere Health are also planning additional online sessions in January.
Some Texas physicians may already be familiar with Cohere Health’s platform, as the company manages prior authorization for health plans such as Humana in the Lone Star State. Physicians already using the Cohere Health online portal for commercial insurance and Medicare Advantage requests will need to verify they’re eligible to submit Medicare prior authorization requests, Dr. Covino says.
Physicians new to Cohere Health can register online, then log in to file new requests. Physicians can also check the status of existing requests via a dedicated website page and visit a resource page for additional information.
Though the program officially starts Jan. 1, 2026, “WISeR participants and MACs will not begin accepting prior authorization requests from WISeR providers and WISeR suppliers until Jan. 5, 2026,” per CMS. “This later date is intentional and is designed to allow sufficient lead time to process requests and ensure adequate time for scheduling affirmed services.”
CMS also notes, “Prior authorization requests submitted on or after Jan. 5, 2026, will apply to services rendered on or after Jan. 15, 2026.” A Cohere Health spokesperson says services rendered before Jan. 15 do not need prior authorization or prepayment review.
Though physicians and staff members won’t be able to submit WISeR documentation directly via electronic health record systems, they’ll be able to use PDFs and other standard medical documentation file formats. If submitting directly to the Cohere Health portal, which will enable the fastest results, the system will read documents in real time and prompt the user for other documents needed.
Email, phone, and fax submissions are also acceptable, though not processed as quickly as portal submissions.
Should Cohere Health’s artificial intelligence-driven system flag a physician’s prior auth request for review, it will move to the clinician review phase. A physician requesting a peer-to-peer review will work with a Cohere Health physician sharing the same specialty. If Cohere denies a prior authorization request, Novitas will conduct any subsequent appeals.
Dr. Covino says 70% of Texas’ WISeR requests are expected to come from physicians who have previously used the Cohere Health platform, based on data CMS has shared with Cohere. The company is still calculating how many Texas physician requests it may field in 2026.
Cohere also maintains a 94% satisfaction rating nationally, based on user surveys it conducts.
“We already have great relationships with the Texas orthopedic surgeons and pain docs,” said Traci Granston, MD, Cohere Health’s senior vice president of clinical strategy.
TMA’s new WISeR resource page features a Cohere Health FAQ among other materials, including CMS’ WISeR Provider Supplier Guide with WISeR prior auth process flow chart (on page 12 of the 72-page PDF).
To learn more about WISeR and the 2026 Medicare Physician Fee Schedule while earning CME, physicians who missed TMA’s Nov. 20 live webinar can view the recording.
Phil West
Associate Editor
(512) 370-1394
phil.west[at]texmed[dot]org
Phil West is a writer and editor whose publications include the Los Angeles Times, Seattle Times, Austin American-Statesman, and San Antonio Express-News. He earned a BA in journalism from the University of Washington and an MFA from the University of Texas at Austin’s James A. Michener Center for Writers. He lives in Austin with his wife, children, and a trio of free-spirited dogs.