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

[GailL1]

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.

[shamit]

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. 

[GailL1]

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 

[shamit]

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,  

[GailL1]

Yep, the companies are the ones that will be testing the AI in these diagnosis / treatment areas.  

We have had CMS listed prior approval methods for a long time.  Especially for some diagnosis/treatments.  Then there are also claim reviews done after the fact that can recover monies from providers for services deemed medically unnecessary.  

We spend a ton of money keeping up Medicare National and Local Coverage Determinations - these should be put to good use to hold down cost and promote the best practices methods that have been proven by science.  

CMS.gov- Medicare FFS - Prior Authorization for Certain Hospital Outpatient Department (OPD) Service... 

These are not new - We have been adding to the list for a long time.

The following hospital OPD services will require prior authorization when provided on or after July 1, 2020:

• Blepharoplasty
• Botulinum toxin injections
• Panniculectomy
• Rhinoplasty
• Vein ablation

The following hospital OPD services will require prior authorization when provided on or after July 1, 2021:

• Implanted Spinal Neurostimulators
• Cervical Fusion with Disc Removal

The following hospital OPD services will require prior authorization when provided on or after July 1, 2023:

• Facet Joint Interventions

Then to the left you will see others that are in other areas of coverage -

• Prior Authorization of /Repetitive, Scheduled Non-Emergent Ambulance Transport
• Prior Authorization process for certain Durable Medical Equipment, Prosthetics, Orthotics and DMEPOS supply items
• Pre-claim Review of some Home Health Services
• As well as Pre-claim review of some Inpatient Rehab Services

None of these are new - Personally, I support the effort to try and  cut out the medically unnecessary services.  I also support not paying for services and procedures that damage more than help as proven by best practices.