Some health systems have been gearing up for a Medicare prior authorization pilot, the Wasteful and Inappropriate Service Reduction model from CMS. But the program is under fire, with six House Democrats, including two physicians, introducing legislation to shut it down.
Here are four things to know about the program and legislation:
- WISeR would implement prior authorization for traditional Medicare across six states starting next year. CMS said the pilot would leverage companies’ AI tools to expedite reviews.
- The program previously received backlash from the American Hospital Association, and House Democrats have been vocal over their concerns with the AI use.
- One sticking point: CMS will pay third parties based on “averted expenditures.”
- “As a doctor and former chief medical officer of Sacramento County, I’ve seen how harmful prior authorization can be when it delays or denies necessary care for patients,” Rep. Ami Bera, MD, D-Calif., said. “The WISeR model takes that a step further by financially rewarding companies for denying care through so-called ‘averted expenditures.’ That creates a dangerous incentive to put profits ahead of patients’ health. These decisions should be made by doctors, not by algorithms designed to cut costs. We should be working to strengthen Medicare, not layering on more red tape that threatens access to timely, high-quality care.”
- Some of the legislators involved with this bill also backed legislation last year to reform prior authorization in Medicare Advantage. Rep. Mark Pocan, D-Wis., who is behind this bill, and Rep. Jan Schakowsky, D-Ill., previously introduced a resolution opposing next year’s program.
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