Starting in January, about 6.4 million Americans enrolled in traditional Medicare in New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington state will be part of a pilot program using artificial intelligence for prior authorizations. The program — known as the Wasteful and Inappropriate Service Reduction (WISeR) model — will require additional approvals for 17 different medical procedures.
Prior authorization means getting approval before an insurer will pay for a medical service or drug. Traditional Medicare currently has fewer prior-authorization requirements than Medicare Advantage, which is the private-plan alternative to Medicare.
The WISeR program is part of the Trump administration’s efforts to cut what it calls waste, fraud and abuse in government. The program, however, has drawn the ire of physicians and Democratic legislators who say the program could delay or deny care for vulnerable patients.
The WISeR program will focus on 17 specific medical services in the first year of the six-year pilot program. Examples include skin and tissue substitutes, electrical nerve-stimulator implants and knee arthroscopy for osteoarthritis. Those procedures are done on an outpatient basis. The program will exclude inpatient-only services, emergency services and services that would pose a substantial risk to patients if significantly delayed, the Centers for Medicare & Medicaid Services said.
Prior authorization means getting approval before an insurer will pay for a medical service or drug. Traditional Medicare currently has fewer prior-authorization requirements than Medicare Advantage, which is the private-plan alternative to Medicare.
The WISeR program is part of the Trump administration’s efforts to cut what it calls waste, fraud and abuse in government. The program, however, has drawn the ire of physicians and Democratic legislators who say the program could delay or deny care for vulnerable patients.
The WISeR program will focus on 17 specific medical services in the first year of the six-year pilot program. Examples include skin and tissue substitutes, electrical nerve-stimulator implants and knee arthroscopy for osteoarthritis. Those procedures are done on an outpatient basis. The program will exclude inpatient-only services, emergency services and services that would pose a substantial risk to patients if significantly delayed, the Centers for Medicare & Medicaid Services said.
