CMS to Test Prior Authorization Model in Traditional Medicare Save

The Centers for Medicare & Medicaid Services (CMS) announced a new experimental model late last week to streamline some prior authorizations under the traditional Medicare program, but some politicians and experts are concerned that it could result in more delays in care.

Under the model, known as the Wasteful and Inappropriate Service Reduction (WISeR) Model, "CMS will partner with companies specializing in enhanced technologies to test ways to provide an improved and expedited prior authorization process" under traditional Medicare, the agency said Friday in a press release, adding that the model will help "patients and providers avoid unnecessary or inappropriate care and [will safeguard] federal taxpayer dollars."

The WISeR Model will test new technologies including artificial intelligence to see whether they can expedite the prior authorization processes for certain items and services "that have been identified as particularly vulnerable to fraud, waste, and abuse, or inappropriate use," the press release noted. "These items and services include, but are not limited to, skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy for knee osteoarthritis."

The model excludes inpatient-only services and emergency services, as well as "services that would pose a substantial risk to patients if significantly delayed."

The announcement came only a few days before the Justice Department announced a major healthcare fraud takedown that included $1.1 billion in alleged Medicare fraud related to the use of skin substitutes.

"As alleged, certain defendants targeted vulnerable elderly patients, many of whom were receiving hospice care, and applied medically unnecessary amniotic allografts to these patients' wounds," the Justice Department said in a press release. "Many of the allografts allegedly were applied without coordination with the patients' treating physicians, without proper treatment for infection, to superficial wounds that did not need this treatment, and to areas that far exceeded the size of the wound."

The seven defendants charged in the wound care scheme -- for which some allegedly received "millions" in illegal kickbacks -- are located in Arizona and Nevada; five of them are medical professionals, according to the department.

Companies selected to participate in the WISeR Model "must have clinicians with appropriate expertise to conduct medical reviews and validate coverage determinations," CMS said. And although technology will help in the initial process, any final decisions regarding denial of coverage "will be made by licensed clinicians, not machines."

The model will be tested initially only in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington, the agency said in a Federal Register notice.

Rep. Suzan DelBene (D-Wash.), whose state is impacted by the new model, sounded a note of concern. "It's baffling how in one breath the administration is trying to take a victory lap on insurers streamlining prior authorization in Medicare Advantage, and in the other instituting the same delay tactics in traditional Medicare," DelBene said in an email to MedPage Today. She was referring to the administration's announcement last Monday that it had reached agreements with major insurers to simplify -- and in some cases cut down on -- the use of prior authorization by health plans, including those participating in Medicare Advantage.

"Traditional Medicare rarely utilizes prior authorization, a factor that many seniors take into account when choosing between it and Medicare Advantage," DelBene said. "The recent announcement leaves us with more questions than answers, especially given the lack of meaningful bipartisan engagement with Congress beforehand. I'm working to get clarity from the administration on how these changes will be implemented and what accountability patients and providers have when care is unnecessarily delayed or denied."

DelBene is the chief sponsor of the Improving Seniors' Timely Access to Care Act, which would establish a standard process for electronic prior authorizations and encourage plans to adopt prior authorization programs that adhere to evidence-based medical guidelines, among other provisions.

Michael Baker, director of healthcare policy at the American Action Forum in Washington, a center-right think tank focused on domestic economic and fiscal policy issues, also had some concerns. While WISeR seeks to address fraud, waste, and abuse, it "does so in a way that won't achieve broad impact on Medicare fee-for-service spending or quality of care," he said in an email.

"The model participants are not healthcare providers or systems; they are technology companies that wouldn't normally be a part of the healthcare system beneficiaries interact with," Baker said. "Adding a duplicative third party to the already established Medicare Administrative Contractor network, particularly one that may be using untested artificial intelligence, machine learning, or algorithmic decision logic, may only increase the overall administrative burden and delay beneficiary care."

"This model also appears to be at odds with the commitment to reducing prior authorization the Trump administration recently touted," he continued. "Introducing new services subject to prior authorizations for Medicare beneficiaries while claiming credit for reducing other prior authorizations is counterintuitive and inconsistent. In the Federal Register notice, CMS cited market research from Medicare Advantage organizations as the inspiration for the WISeR model. Those same organizations, however, have committed to reducing prior authorization due to beneficiary concerns and the changing care environment."