Dive Brief:
- Senate Democrats are trying to roll back a pilot program that adds artificial intelligence-backed prior authorization for some services in Medicare.
- Sens. Ron Wyden, D-Ore., Maria Cantwell, D-Wash., Richard Blumenthal, D-Conn., and Kirsten Gillibrand, D-N.Y., introduced a resolution Wednesday that would invoke the Congressional Review Act — a legislative tool lawmakers can use to overturn agency actions — to end the WISeR model, which went into effect in six states this year.
- Democrats have railed against the pilot for months, arguing the model delays or denies Medicare beneficiaries’ care. “Americans are sick and tired of abusive prior authorization tactics putting needed health care out of reach,” Wyden said in a statement. “The last thing seniors need is even more AI denying the care they need.”
Dive Insight:
The program, called the Wasteful and Inappropriate Service Reduction model, was announced by the CMS last summer as part of a bid to crack down on what the agency said was fraud and wasteful spending in Medicare.
Under the model, the federal government contracts with private companies to implement AI-backed prior authorization for some care deemed vulnerable to fraud, like skin and tissue substitutes and epidural steroid injections for pain management.
Regulators say the policy targets a narrow set of services to prevent patient harm from inappropriate care and tamp down on unnecessary spending.
But prior authorization is rare in traditional Medicare, and providers have long argued the practice delays care and creates heaps of administrative work.
Democrat lawmakers have pushed back on the model. Last year, House Democrats introduced legislation to repeal the model, though the bill failed to gain traction. And in April, Cantwell released a report that found procedures subject to prior authorization in Washington were taking weeks longer to be approved, adding red tape for providers and patients.
Now, Democrats are using another method to end the WISeR pilot. The Congressional Review Act requires agencies to submit rules to Congress before they can take effect and creates a set of procedures that lawmakers can use to overturn regulations if approved by both houses and signed by the president.
WISeR is subject to the review, the Government Accountability Office said last week. The HHS didn’t submit the model to Congress when it was announced, arguing the notice was a guidance document that wasn’t affected by the law.
However, the GAO determined the pilot is agency rulemaking, given it creates new requirements under traditional Medicare that affects providers and beneficiaries.
The decision starts a 60-day period where lawmakers can force a vote to repeal the model, according to Senate Democrats.
Twenty senators have signed onto the resolution, including Ruben Gallego, D-Ariz., Ed Markey, D-Mass., Cory Booker, D-N.J., and Dick Durbin, D-Ill.
