CMS responds to criticism of pay model targeting ‘wasteful and inappropriate’ radiology services
The Centers for Medicare & Medicaid Services is responding to criticism of a newly announced pay model targeting low-value interventional radiology services.
Seventeen House Democrats earlier this month penned a letter to CMS Administrator Memet Oz, MD, MBA, about the issue. Their concern stems from the planned Jan. 1 rollout of the Wasteful and Inappropriate Service Reduction (or “WISeR”) Model across six states.
WISeR will target more than a dozen services it says are often subject to abuse, including image-guided decompression of the spine, epidural steroid injections for pain management (excluding facet joints) and percutaneous vertebral augmentation. However, lawmakers led by Reps. Ami Bera, MD, D-Calif., and Suzan DelBene, D-Wash., are worried WISeR will bring more red tape to the Medicare program while delaying necessary healthcare services.
Days after the message, CMS on Aug. 12 issued a new “frequently asked questions” fact sheet addressing some of the representatives’ concerns.
“The WISeR model reflects the CMS Innovation Center’s commitment to protect federal taxpayers and the Department of Health and Human Services and CMS pledge to protect people with original Medicare by crushing fraud, waste and abuse,” the agency noted.
WISeR will last through 2031, targeting IR and other services in New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington. It will exclude several clinical scenarios, among them, inpatient stays, emergency care or instances when prior authorization could pose “substantial risk to patients if significantly delayed.” Model participants are technology companies, rather than physicians, who will use AI to help process requests in fee-for-service Medicare.
CMS said it targeted items and services, citing a history of “fraud, waste, abuse and inappropriate utilization.” It derived the list from a “careful review” of existing national and local coverage determinations, academic literature and reports from the HHS Office of Inspector General.
“An unfortunate truth, as evident by past law enforcement cases, is that some healthcare providers abuse Medicare by providing expensive items or services … in situations where the patients may not benefit and where they do not meet Medicare coverage criteria,” CMS said in the FAQ.
WISeR is meant to improve the “speed, accuracy and consistency” of prior authorization reviews for these services. Model participants will utilize existing Medicare coverage policy, leveraging technology to determine if a claim is payable. The agency hopes to eventually achieve “auto approvals” of requests “wherever possible.”
“Most response times will be within 72 hours and, in many cases, the response will be much faster,” CMS said.
The agency emphasized that participating tech companies will only be compensated if they reduce wasteful, inappropriate care. They’ll receive a percentage of the savings associated with reviews, with Medicare planning to perform “rigorous oversight,” with participants “penalized for inappropriate denials.”
CMS said physicians who “opt” for prior authorization for impacted services will know in advance that they will be paid, as long as Medicare coverage and clinical documentation criteria are met. Physicians in the six covered states who submit a request for covered services will send all relevant info either directly to the tech company or their Medicare Administrative Contractor. WISeR will utilize “enhanced technology” to support coverage determinations and seek reviews by clinicians with relevant expertise “as needed.”
“Providers and suppliers, however, are not required to submit a prior authorization request for a selected service,” CMS said. “Should they choose not to, the claim for that service would be subject to post-service/pre-payment medical review.”
You can read the full FAQ, which also includes details on how physicians can appeal decisions, here.
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.