Beneficiaries of traditional Medicare usually don’t need prior authorization before getting treatment. However, starting in January, a new program from the Centers for Medicare and Medicaid Services (CMS) has introduced prior authorizations into certain parts of traditional Medicare. This includes the use of artificial intelligence to evaluate care applications.
The initiative, called the Wasted and Inappropriate Services Reduction (WISeR) model, requires additional approvals for various procedures. These include epidural steroid injections, spinal stenosis treatments, knee osteoarthritis management, and nerve stimulation for conditions like tremors and Parkinson’s disease.
This six-year pilot project will implement AI-assisted pre-authorization reviews in several states, including New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington, affecting around 6.4 million Medicare beneficiaries. CMS works with private firms to carry out these evaluations using advanced technology, like artificial intelligence.
CMS Administrator Mehmet Oz explained that the goal of WISeR is to eliminate fraud and waste in Original Medicare. Yet, critics argue this could lead to delays and denials similar to what Medicare Advantage participants have experienced.
According to KFF, the pre-approval procedures might complicate administrative processes for healthcare providers and lead to delays or even denials of necessary medical services. In Washington state, for instance, patients have reported waiting up to three weeks for licensing decisions instead of just days. Senator Maria Cantwell from Washington pointed out that these delays are affecting older adults’ access to timely healthcare.
During a recent Senate Finance Committee hearing, Health and Human Services Secretary Robert F. Kennedy Jr. acknowledged the existence of “kinks in the system” and indicated a desire to address them. Cantwell noted that processes that once took less than two weeks now take four to eight weeks, forcing patients to reschedule treatments and potentially worsening their conditions.
David Lipshutz, co-director of the Medicare Advocacy Center, commented that the pilot programs haven’t been running smoothly, expressing frustration from both beneficiaries and providers across states. He noted that this model seems to bring in some of the less favorable aspects of Medicare Advantage.
Most Medicare Advantage enrollees, about 99%, typically need prior authorizations for expensive medical care. There’s a concern that while traditional Medicare had limited prior authorization processes, those decisions were made by contractors without financial motives. In contrast, under WISeR, independent vendors have a stake in reducing spending, which could incentivize denials of service.
One growing concern is the potential for WISeR to expand further. Lipshutz remarked that even if certain services or regions aren’t covered now, that could change in the future.
