Dive Brief:
- Democrat lawmakers are calling on the CMS to release more data on a controversial pilot program that adds artificial intelligence-backed prior authorization for some services in traditional Medicare.
- In a letter sent to CMS Administrator Dr. Mehmet Oz on Monday, representatives pushed the agency to release information on how long it takes technology vendors to reach a prior authorization determination, the number of requests that are approved or denied and how many beneficiaries appeal, among other clarifications.
- It’s another salvo from lawmakers concerned the pilot is delaying and denying Medicare beneficiaries’ care. The CMS said it would review the letter and respond directly to members of Congress.
Dive Insight:
Under the program, called the Wasteful and Inappropriate Service Reduction, or WISeR, model, the federal government contracts with private companies to add prior authorizations for certain services deemed vulnerable to abuse and wasteful spending, like skin and tissue substitutes or epidural steroid injections for pain management.
The pilot went into effect in six states this year, and it’s scheduled to run through 2031. The CMS argues the model will curb low-value and costly care that has limited benefit for patients.
But providers, patient advocates and lawmakers — particularly Democrats — have pushed back, arguing WISeR is worsening access to care for Medicare seniors and heaping new administrative burdens on providers.
“That’s what happens when you roll out a program without proper vetting, without transparency and without safeguards,” Rep. Suzan DelBene, D-Wash., one of the signers of the letter, said during a press conference Monday. “Washington seniors should not be the guinea pigs for the administration’s AI experiment.”
This spring, Democrats in the House and Senate introduced resolutions to roll back the program. And earlier this month, a House committee unanimously voted to add an amendment to the HHS’ 2027 spending legislation that would block funds from being used for the pilot.
Now, 31 House Democrats, including Reps. Ami Bera, D-Calif., Lloyd Doggett, D-Texas, Alexandria Ocasio-Cortez, D-N.Y., and Mark Pocan, D-Wis., are looking for more data on how WISeR has been implemented.
For example, the CMS said the turnaround time for prior authorization determinations in WISeR would range from one to three days, according to the letter. But that time frame appears to only reflect the amount of time it takes for a vendor to reach a decision, and not when a physician receives a tracking number to proceed with the claim submission.
The lawmakers asked for the average time it takes from vendor determination to the issuance and physician receipt of a tracking number. The letter also requests data on the top reasons for request dismissals and the average time it takes from initial submission to the final claim payment, among other metrics.
Additionally, lawmakers want more information on peer-to-peer review — requests by providers for a clinical assessment after a treatment is denied — including how long physicians are forced to wait and the number of decisions overturned after a review.
The letter also asks for details on oversight of the model, like when WISeR audits will be released, how the CMS determines success for vendors participating in the pilot and what metrics the agency uses to decide whether to remove companies from the program.
Virtix, the firm handling WISeR claims in Washington, has already been ordered by the CMS to submit a corrective action plan for not complying with the pilot’s 72-hour prior authorization review requirement, according to DelBene.
Virtix said it hasn’t received a corrective action plan. But the CMS audits WISeR participants to prevent inappropriate denials and ensure accountability against performance metrics, a spokesperson said in a statement to Healthcare Dive.
“As the WISeR participant in Washington State, we work with CMS to review workflows and processes to identify opportunities for improvement. Recommendations arising from these evaluations are expected periodically, and we will incorporate them as part of our ongoing commitment to the WISeR program,” they said.
