Medicare Prior Authorization Pilot Faces Early Criticism

Traditional Medicare beneficiaries generally do not need prior authorization before receiving medical treatment.

Healthcare providers are reviewing patient authorization requests under Medicare's new AI-assisted pilot program. (Photo: Carol M. Highsmith, Library of Congress)

However, a new pilot program launched by the Centers for Medicare and Medicaid Services (CMS) in January introduced prior authorization requirements, including the use of artificial intelligence to review requests for certain treatments, Kerry Hannon reported for Yahoo Finance.

The program, known as the Wasteful and Inappropriate Service Reduction (WISeR) model, requires additional approvals for procedures such as epidural steroid injections, treatments for spinal stenosis and knee osteoarthritis, and nerve stimulation therapies for conditions including tremors and Parkinson's disease.

The six-year pilot program applies AI-assisted prior authorization reviews to selected services in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington, affecting approximately 6.4 million traditional Medicare beneficiaries.

CMS contracts private companies to use enhanced technologies, including artificial intelligence, to conduct the reviews.

According to CMS Administrator Mehmet Oz, the initiative is intended to reduce fraud, waste and abuse within Original Medicare.

Critics argue that the program could create the same delays and denials that have long frustrated Medicare Advantage enrollees.

According to a report by KFF, prior authorization requirements can increase administrative burdens for healthcare providers, delay patient care and, in some cases, result in the denial of medically necessary treatments.

Those concerns are already emerging. In Washington state, patients reportedly are waiting up to three weeks for authorization decisions rather than receiving approvals within days, leading to longer waits for procedures, according to a report by Sen. Maria Cantwell.

"For Washington's seniors, WISeR is overriding doctors to delay care and deny treatment," Cantwell said in a statement.