A group of House Democrats is seeking answers from CMS Administrator Mehmet Oz, MD, regarding a new initiative that will add prior authorization for some traditional fee-for-service Medicare services.
The 17 House Democrats said in their Aug. 7 letter that the use of prior authorization “shows us that, in practice, [this proposal] will likely limit beneficiaries’ access to care, increase burden on our already overburdened health care work force, and create perverse incentives to put profit over patients.”
Under the Wasteful and Inappropriate Service Reduction (WISeR) 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 services.
The model is beginning with providers in Arizona, Washington, New Jersey, Texas and Oklahoma.
The lawmakers noted in their letter that the introduction of the WISeR model came shortly after White House officials “publicly touted” the health insurance industry’s series of commitments to streamline, simplify and reduce prior authorization requirements across commercial, Medicare Advantage and managed Medicaid plans.
“It is also troubling that the WISeR model is expected to contract with entities including Medicare Advantage plans — the very entities that have abused prior authorization for Medicare patients enrolled in private plans — to run these demonstrations,” they said in the letter. “The model is described as voluntary, but it is only voluntary for the model participants.”
The lawmakers are seeking answers regarding how the model will be implemented. Questions include:
- What criteria were used to select the six states for this model?
- What services will be subject to prior authorization in each state?
- How will entities performing prior authorization be selected? What qualifications will be required to ensure that reviewers have appropriate expertise?
- Has CMS studied how prior authorization in traditional Medicare may increase rates of physician burden and burnout?
They are asking for a response by Sept. 1.
