Prior Auth Comes to Medicare

Bravo! Sounds great

DaisyDay said:

CMS to Test Prior Authorization Model in Traditional Medicare

The model could make things worse, observers say

www.medpagetoday.com

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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 releaseopens in a new tab or window, adding that the model will help "patients and providers avoid unnecessary or inappropriate care and [will safeguard] federal taxpayer dollars."​

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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 substitutesopens in a new tab or window, electrical nerve stimulator implants, and knee arthroscopy for knee osteoarthritis."​

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Yep they will save in fraud I think while at the same time deny needed treatments. AI is now the gatekeeper to USA elder care.

Richard T said:

Yep they will save in fraud I think while at the same time deny needed treatments. AI is now the gatekeeper to USA elder care.

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If people die whilst awaiting prior-auth…think of the savings!

Prior Auth slows and/or prevents care while increasing administrative costs for doctors.

Death panel ---> Death bots

Totally opposed to this. Why should people have to delay care to catch fraud? Why can’t catching fraud be done in parallel to not having to do prior authorizations?

Always in His Presence said:

Bravo! Sounds great

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Remembering the disclosure about ten years ago give or take: "fake news"......

"Humane healthcare for me, managed bureaucracy for thee"

Private health insurers use AI to approve or deny care. Soon Medicare will, too.​

A pilot program testing the use of artificial intelligence to expand prior authorization decisions in Medicare has providers, politicians and researchers asking questions.

Taking a page from the private insurance industry’s playbook, the Trump administration will launch a program next year to find out how much money an artificial intelligence algorithm could save the federal government by denying care to Medicare patients.

The pilot program, designed to weed out wasteful, “low-value” services, amounts to a federal expansion of an unpopular process called prior authorization, which requires patients or someone on their medical team to seek insurance approval before proceeding with certain procedures, tests, and prescriptions. It will affect Medicare patients, and the doctors and hospitals who care for them, in Arizona, Ohio, Oklahoma, New Jersey, Texas, and Washington, starting Jan. 1 and running through 2031.

Nearly three-quarters of respondents thought prior authorization was a “major” problem in a July poll published by KFF, a health information nonprofit that includes KFF Health News.

[Both private insurers and Medicare say all decisions will be reviewed by a human.]

“I think that there’s also probably a little bit of ambiguity over what constitutes ‘meaningful human review,’” said Amy Killelea, an assistant research professor at the Center on Health Insurance Reforms at Georgetown University.

A 2023 report published by ProPublica found that, over a two-month period, doctors at Cigna who reviewed requests for payment spent an average of only 1.2 seconds on each case.