OK doctor weighs in on prior authorization for select Medicare services starting Jan. 1, 2026
OKLAHOMA CITY (KFOR) — Changes are on the horizon for Medicare patients, regarding certain services moving to prior authorization.
In 2026, the Centers for Medicaid and Medicare Services will implement a prior authorization for certain services covered under Medicaid in Oklahoma, Ohio, Texas, Arizona, New Jersey, and Washington.
With the impending changes, local doctors have concerns about the accessibility of treatment for patients.
"It will limit access for patients to have physicians because the physicians will just simply not see their Medicare patients or they will not see any Medicare patients," said Dr. Mary Clarke, former President of the Oklahoma State Medical Association.
See the list of services that will need prior authorization here.
CMS says it's part of an effort to target wasteful and inappropriate services..
However, Dr. Mary Clarke believes there's a bigger issue beneath the surface.
"The same amount of money that's going into Medicare is covering two to three times the amount of people that were there 30 years ago. So, what do you think is going to happen if you don't put more money in, but you have three times more people? The only thing you can do is deny coverage for those extra people," said Dr. Clarke.
CMS claims there's a risk of fraud, waste, and abuse for services that have little to no clinical evidence based benefit.
News 4 reached out to CMS to see why Oklahoma is included in the handful of states, or if there is any fraud currently happening in OK that they know about.
We're waiting to hear back; however, they did ask that we give them 24 hours for a response.
Dr. Clarke worries prior authorizations could create a bigger burden for doctors if a patient needs a specific treatment to survive.
"We're probably going to take care of them right then, knowing that that's the right thing to do, and if a denial comes back, then they just won't pay for it. And then the medical system, your doctor's office, your hospital, just doesn't get paid," she said.