Community Champion ⭐⭐⭐

Traditional Medicare - Prior Approvals Testing Model - JUST SO YOU KNOW

Forum|Forum|1 year ago
July 2, 2025
5 replies
2057 views

Becker Hospital Review 06/30/2025 - CMS to add prior authorization for traditional Medicare services

This really isn't a big deal but I thought I would keep the beneficiaries here abreast of these new items that are being added for prior approval under Traditional Medicare. Each is more specific in how it is described here in a simple fashion. Your doc or specialist should know if any procedure you are having would need this extra step of OK because at present it is more of a test to see the results.

from the link ~

CMS has unveiled the Wasteful and Inappropriate Service Reduction model, a new Innovation Center initiative that will add prior authorization for some traditional fee-for-service Medicare services.

Under the model, CMS will partner with companies specializing in AI and machine learning to test ways to provide an improved and expedited prior authorization process for certain Medicare services. Companies hired to manage the initiative will be paid based on how much money they save the federal government by stopping payment for unnecessary or non-covered items services.

The model is beginning with providers in Arizona, Washington, New Jersey, Texas and Oklahoma.

The 17 initial targeted services include those particularly vulnerable to fraud, waste and inappropriate use, according to CMS. They include deep brain stimulation for Parkinson’s Disease, epidural steroid injections for pain management, cervical fusion, skin and tissue substitutes and arthroscopy for knee osteoarthritis.

“The WISeR Model will help root out waste in original Medicare,” CMS Administrator Mehmet Oz, MD, said in a news release. “Combining the speed of technology and the experienced clinicians, this new model helps bring Medicare into the 21st century by testing a streamlined prior authorization process, while protecting Medicare beneficiaries from being given unnecessary and often costly procedures.”

There is more at the link - WISeR will run from Jan. 1, 2026 through Dec, 31, 2031.

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shamit

Contributor ⭐⭐⭐

I am glad you think this is no big deal. I happen to think this is. If you have original Medicare you will have to get prior approval just like a Medicare Advantage plan. And they will be using AI. I certainly see many errors in AI, I don't trust ot. They will be doing denials to save money just like Medicare Advantage Plans.

So if you live in one of these 5 states you will have to jump through hoops to get certain care. I live in one of these states. We have been ranked as having the second worst healthcare in the country. This absolutely won't help that. And we get to pay extra for a Medigap plan to cover the 20% that Medicare decides to be generous enough to cover. It is a trial, with us being the guinea pigs for 5 years, for changing everyone over to a Medicare Advantage type plan, but probably with higher costs to us.

GailL1Author

Community Champion ⭐⭐⭐

Medicare has had prior approvals for many procedures even before this - so adding a few more especially the ones where there could be some abuses is not a big deal but an important one.

Yes, we do have to get a handle on Medicare expenditures - all of it and this is just one step towards thar goal. But this is currently a test model to see how it goes -

Prior approvals in and of themselves are necessary to keep down unnecessary cost, the problem now is the time delay in getting them turned around - and setting up a process for this to be done fast and accurately. By doing it this way, providers will begin to understand their responsibility in having and supplying all necessary info for the necessity of the service -

CMS is now trying to bring the MA insurers in line on these prior approvals - same thing, setting up a procedure for them to follow as to when, and where and how so that nobody is missing needed care.

If CMS is gonna ask private MA insurers to do it right then they also feel that the Traditional program needs to have some of the same oversite too.

Yes, AI has it's limits now - I believe that is part of the testing. But if this type of expenditure review is gonna take place, I don't see any other way than technology cause it certainly will be difficult for a human to actually do the checking - but checking AI would be easier and then if incorrect, making it right.

Like I said, this isn't new - just some steps forward. Adding more services that have some suspect as medically necessary - just like the ones on the books already.

AXIOS 03/01/2024 - Why Medicare is adding prior authorization requirements as others cut back

IT‘S ALWAYS SOMETHING . . . . .. . . . Roseanne Roseannadanna

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shamit

Contributor ⭐⭐⭐

And the way the companies administering this will get paid is by the amount of money they save the government. Not decisions by CMS. And the procedures listed are for the initial year. That implies more will be added each year. Part of the uproar going on about Medicare Advantage plans is the denials of treatment. These private MA companies make their money by not spending as much of the government gives them.

5 years of us being denied treatment that people in the other 45 states will still be able to get just isn't right. Don't try to tell me that paying a company based of the money they save the government will not lead to many more denials than in the past,

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jslindgren

Contributor ⭐

Thank you for alerting to this. I think this is another step towards privatizing Medicare, and is not right for many reasons. Here is a statement from prior health care administrators that describes many reasons to oppose this plan. Thank you.

As former government officials, providers, policy experts, researchers, and patients, we are concerned about the design of the model and recommend it not be initiated. Our specific concerns are outlined below.

1. Participant payment model: The WISeR model proposes to compensate the private companies participating “based on a share of averted expenditures.” This payment structure immediately creates an incentive for companies to avert more expenditures by denying more prior authorization requests in order to increase their compensation. Evidence from government agencies and experts across the political spectrum has demonstrated that MA prior authorization, which also results in additional retained revenue when care is denied, very often improperly denies care. (1,2) A participant payment model that mirrors the current incentives in MA is likely to fall victim to the same misaligned incentives and lead to delays and denials of needed care.

2. Participant selection: The model intends to allow participants who are currently administering prior authorization processes for private payers, including MA companies. Currently, the Medicare Administrative Contractors (MACs) that administer prior authorizations in TM have an accuracy rate of over 98%. (3) Further, MAC prior authorization decisions are overturned less than half as frequently (roughly 35%) as decisions made by private companies administering MA prior authorization with an 81.7% overturn rate. (4) Thus, the participants desired for the WISeR model have demonstrated inferior performance in making accurate prior authorization decisions, which have resulted in serious harm and death to patients. (5) These same bad actors should not be given the ability to make these decisions in TM.

3. Prior authorization protocols: The lack of transparency in MA prior authorization makes it impossible to justify expanding these processes into TM, based on evidence of their accuracy or benefit to patients and providers. MA insurers do not report prior authorization decisions based on type of service, contract, or reason for denial. Additionally, the protocols used to review prior authorizations in MA are not disclosed to patients, providers, or policymakers. Given that prior authorization in MA is a black box with documented adverse effects on patients and moral injury to providers, expanding the process without a full public audit of how it is currently conducted with recommendations for improvement is risky. (6)

4. Use of enhanced technology: The model references the use of enhanced technologies for prior authorization review. However, these technologies, particularly the use of artificial intelligence (AI) systems, have been associated with significantly higher rates of care denials. For instance, internal documents from MA insurers demonstrate that denials for post-acute care services rose sharply following the implementation of AI-driven review processes administered by naviHealth, a subsidiary of UnitedHealth Group. (7) Often these denials in MA are inappropriate as the Department of Health and Human Services Office of the Inspector General and whistleblowers have demonstrated. (8,9) This, combined with the lack of transparency into the methodologies behind the enhanced technologies used by private insurers (the intended model participants) could result in delays and denials of needed care for seniors and people with disabilities enrolled in TM.

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