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Traditional Medicare beneficiaries generally don’t need prior authorization before receiving medical treatment.
In January, however, a new pilot program launched by the Centers for Medicare and Medicaid Services (CMS) began bringing prior authorization, including the use of artificial intelligence to review requests for care, to parts of traditional Medicare.
And it’s not going smoothly.
The program, known as the Wasteful and Inappropriate Service Reduction (WISeR) model, requires additional approvals for a range of procedures, including epidural steroid injections, treatments for spinal stenosis and knee osteoarthritis, and nerve stimulation for conditions such as tremors and Parkinson’s disease.
The six-year pilot applies AI-assisted prior authorization reviews to certain services in New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington, affecting roughly 6.4 million traditional Medicare beneficiaries. CMS contracts with private companies to use “enhanced technologies, including artificial intelligence,” to conduct reviews.
The aim of WISeR is to slash “crushing fraud, waste, and abuse … and root out waste in Original Medicare,” CMS administrator Mehmet Oz said in a statement.
Critics contend it could create the same delays and denials that have frustrated Medicare Advantage enrollees for years.
This preauthorization process and requirements can lead to administrative hassles for providers, delays for patients, and, in some instances, denials of medically necessary services, according to a KFF report.
And that is what’s happening. In the state of Washington, patients are waiting up to three weeks instead of days for authorization decisions and significantly longer for procedures, according to a report from Sen. Maria Cantwell (D-Wash.).
“For Washington’s seniors, WISeR is overriding doctors to delay care and deny treatment,” Cantwell said in a statement.
During a Senate Finance Committee hearing in April, Health and Human Services Secretary Robert F. Kennedy Jr. acknowledged that there were “probably kinks in the system” and said they would be straightened out.
“Procedures that were typically completed within two weeks prior to WISeR now take four to eight weeks,” Cantwell wrote in a letter to Kennedy. “That frequently forces patients to reschedule care multiple times, prolonging pain and allowing underlying conditions to worsen.”
The ‘worst’ of Medicare Advantage
“The pilot is not going smoothly anywhere,” David Lipschutz, co-director of the Center for Medicare Advocacy, told Yahoo Finance. “From what we’ve heard, it’s frustrating both beneficiaries and providers in every state. This model appears to be importing some of the worst elements of Medicare Advantage.”
