With Q4 2025 underway, the outlook for procedural and surgical care is shifting as new policies take aim at how services are authorized and reimbursed.

The Centers for Medicare & Medicaid Services (CMS) has steadily expanded prior authorization and pre-claim review programs in an effort to safeguard Medicare funds and reduce billing errors. These programs are now extending more deeply into procedural and surgical specialties, which means both clinical and financial operations will feel the effects. Although CMS frames these requirements as protections for patients and taxpayers, they represent a new reality for outpatient procedural practices, ambulatory surgery centers (ASCs), and hospital outpatient departments (HOPDs).

To understand what this means, it is helpful to start with how these programs function at the ground level.

Prior authorization (PA) requires providers to submit documentation and receive approval before performing a service, while pre-claim review (PCR) allows the service to be rendered but delays the claim until documentation is reviewed. In both cases, the medical necessity rules remain unchanged. What shifts is the timing of submission.

CMS argues that this earlier review helps reduce denials and appeals, providing providers with greater certainty of payment. With that said, CMS has been steadily expanding these requirements over time. Since 2020, CMS has widened the scope of services that require prior authorization (from cosmetic & reconstructive procedures to now including spinal neurostimulators, cervical fusions, and facet joint interventions).

What changes after 2025:

• Medicare expansion in 2026 (WISeR model): From 2026–2031, Original Medicare will pilot prior authorization in six states (AZ, NJ, OH, OK, TX, WA). Targeted outpatient services include skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy for knee osteoarthritis. Providers must either obtain prior authorization before rendering care or accept pre-payment medical review if they skip it.
• Hospital Outpatient Department (OPD) prior authorization (ongoing): Nationwide rules continue to apply for specific services such as blepharoplasty, rhinoplasty, panniculectomy, vein ablation, botulinum toxin injections, cervical fusion with disc removal, implanted spinal neurostimulators, and facet joint interventions. CMS requires determinations within 7 calendar days (2 business days if expedited), decisions remain valid for 120 days, and OPD providers with at least 90% affirmation across 10 or more cases may qualify for exemption.

...and more.

Starting in 2026, CMS will require procedural and surgical specialties to meet just a few key standards: obtain prior authorization for targeted outpatient services in pilot states, follow existing OPD rules for designated procedures, and prepare for new seven-day and 72-hour decision clocks in MA, Medicaid, and CHIP, supported by electronic prior auth systems. These requirements don’t add new clinical documentation, but they do shift when and how it must be submitted, making early, accurate preparation the critical factor for avoiding delays and protecting revenue.

Are healthcare providers ready for this change?

The ripple effects of expanded prior authorization are already visible. Surgeons and schedulers must prepare documentation earlier, creating additional strain on pre-admission testing (PAT) teams. Financial exposure grows as incomplete submissions risk delays or denials. Patients may wait longer for necessary care, particularly for time-sensitive procedures, and regional disparities emerge as pilot states shoulder a heavier administrative burden than others.

The most effective strategies start with a close look at internal workflows:

1. Auditing pre-op processes can reveal where missing labs or documentation cause delays.
2. Training staff on new timing rules ensures fewer mistakes at the front end.
3. Technology solutions that automate packet creation or flag missing items help reduce manual burden, while tracking denial data allows leadership to quantify risk and improve processes.
4. Clear communication with patients about the potential for longer timelines can help preserve trust and reduce cancellations.

The bottom line

CMS’s expansion of prior authorization signals a new era of utilization control in outpatient surgical care. What started narrow now shapes how procedures are scheduled, documented, and reimbursed. For providers, the focus must shift from chasing approvals to building systems that keep cases moving and revenue protected.