The Centers for Medicare and Medicaid Services has announced a prior authorization program pilot for original Medicare.
The six-year voluntary Wasteful and Inappropriate Service Reduction Model (WISeR) pilot is being enabled by technology, CMS said. The agency said it would partner with companies specializing in enhanced technologies to test ways to provide an improved and expedited prior authorization process.
Participating providers will have the choice of submitting prior authorization requests for selected items and services or subjecting their post-service claim to prepayment medical review.
The WISeR Model will leverage enhanced technologies, along with human clinical review, to ensure timely and appropriate Medicare payment for select items and services. WISeR will run for six performance years, from January 1, 2026, to December 31, 2031. The application period opened on June 27.
WHY THIS MATTERS
The WISeR Model will test whether enhanced technologies, including artificial intelligence and machine learning, can expedite the prior authorization processes for select items and services that have been identified as particularly vulnerable to fraud, waste, and abuse or inappropriate use, CMS said.
CMS said it plans to partner with third-party entities on a specified list of services, including skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy for knee osteoarthritis.
The model excludes inpatient-only services, emergency services, and services that would pose a substantial risk to patients if significantly delayed.
The WISeR Model will not change Medicare coverage or payment criteria.
Healthcare coverage for original Medicare beneficiaries remains the same and beneficiaries retain the freedom to seek care from their provider or supplier of choice, according to CMS.
The WISeR Model does not impact those enrolled in Medicare Advantage.
Companies selected to participate in the model will operate in assigned geographic regions and must have clinicians with appropriate expertise to conduct medical reviews and validate coverage determinations.
Coverage decisions will be made by licensed clinicians.
Model participants will receive payments based on their ability to reduce unnecessary or noncovered services and lower spending.
Providers and suppliers that choose to submit a prior authorization may either submit their request directly to model participants or to their Medicare Administrative Contractor.
CMS said it may include a pathway in the future to allow providers and suppliers with strong compliance records to qualify for exemptions from WISeR review, which would further reduce administrative burden and allow greater focus on high-risk areas.
CMS has issued a Request for Applications for companies interested in participating in the WISeR Model.
THE LARGER TREND
The model builds on other changes being made to prior authorization as announced by the U.S. Department of Health and Human Services and CMS on Monday.
Waste in healthcare represents up to 25% of healthcare spending in the United States. The Medicare Payment Advisory Commission estimates that up to $5.8 billion in Medicare spending in 2022 alone was spent on services with minimal benefit, CMS said.
ON THE RECORD
"CMS is committed to crushing fraud, waste and abuse, and the WISeR Model will help root out waste in Original Medicare," said CMS Administrator Dr. Mehmet Oz. "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."
Email the writer: SMorse@himss.org