Hospital lobby strongly urges Medicare to delay model targeting ‘wasteful’ radiology services
The American Hospital Association is strongly urging the Medicare program to delay a controversial new care model targeting unnecessary, low-value radiology services.
CMS first announced the Wasteful and Inappropriate Service Reduction (or “WISeR”) initiative in June, which is set to begin Jan. 1 across six states. WISeR will focus on over a dozen services Medicare says are often subject to fraud, including image-guided decompression of the spine, epidural steroid injections for pain management, and percutaneous vertebral augmentation.
However, AHA—which represents over 5,000 hospitals and their 270,000 affiliated physicians—has “substantial concerns” about how WISeR intends to pay participating companies. Medicare will tap tech firms, which will use AI to help root out requests for unnecessary services and other specialties. But AHA believes this “incentivizes denials at the expense of physician medical judgment.”
“CMS has indicated that participating vendors will be compensated by receiving 10%–20% of the savings associated with care denials,” AHA wrote to the Center for Medicare and Medicaid Innovation on Oct. 23. “Such a structure creates a perverse incentive to deny care that otherwise may be appropriate, as vendors may increase their profits by denying care.”
AHA listed several issues with WISeR that must be addressed, including implementing guardrails to track physician involvement in denial determinations and the need for adequate vendor oversight. Hospitals also are “extremely concerned” about the prospect that WISeR could expand to other healthcare services. Given the “enormous disruptions” prior authorization can have on patient access and administrative burden, AHA is asking Medicare to refrain from increasing the number of states involved. It also wants the administration to avoid adding new healthcare services to the model, until after the initial six-year period concludes.
Hospitals are asking for more time leading up to the model starting, given these concerns.
“We strongly encourage CMS to delay implementation of the WISeR model by at least six months,” wrote Ashley Thompson senior VP of public policy analysis and development. “Furthermore, upon eventual implementation, we recommend that CMS implement an operations and testing period during which claims will not be denied as a result of the WISeR model processes, and vendors and physicians can test the technologies and identify any unforeseen issues that may impact patient care.
More on WISeR
The American Medical Association also recently held a webinar about WISeR to share key details with physicians. Both the American College of Radiology and Society of Interventional Radiology reported on the event, sharing key details with their memberships.
During the webinar, Abe Sutton, director of the CMMI, emphasized that the government shutdown will not affect WISeR’s launch. New payment models are being developed and tested at the Innovation Center utilizing separate funding Congress has already appropriated, SIR reported in a post shared Oct. 24.
Medicare is set to launch the initiative on Jan. 1, with it lasting through 2031, operating in n New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington. Physician’s participation in these select states is voluntary, SIR reported, with docs able to either submit a prior authorization requires or choose to undergo a prepayment review. If a claim is rejected, a physician may resubmit the request, pursue peer review or appeal. Those who bypass PA will have claims reviewed prior to payment, with full appeal rights retained in both options, SIR noted.
Medicare also plans to operate a Gold Card program to recognize those who consistently meet Medicare coverage criteria, the society added. This would exempt docs from both PA and prepayment review, with the Gold Card program slated to start sometime in mid-2026.
“Ultimately, WISeR aims to model a better, less burdensome prior authorization process that aligns payment and coverage decisions with clinical evidence, physician input and patient needs, while maintaining transparency, accountability and access to appropriate care,” the society wrote.
In a separate post, the American College of Radiology offered a list of interventional CPT codes impacted by WISeR. These also include vagus, phrenic and electrical nerve simulators, incontinence control devices and cervical fusions, among others. Sutton also confirmed the model doesn’t change physician payments for services selected for PA under the model, ACR emphasized. CMMI’s Sutton also reiterated WISeR will be evaluated based on the accuracy and timeliness of PA determinations, appeal rates for denied claims, and patient experience feedback.
“Radiology practices in affected states should begin preparing for documentation and workflow changes,” ACR wrote, listing important considerations including operational impact, appeals and exemptions, and documentation requirements.
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.