House lawmakers criticize Medicare pay model targeting ‘wasteful’ interventional radiology services
House lawmakers are criticizing a recently introduced pay program that will target inappropriate interventional radiology services delivered to Medicare beneficiaries.
CMS first unveiled the Wasteful and Inappropriate Service Reduction (or “WISeR”) Model on June 27. The agency is partnering with technology vendors, who will utilize artificial intelligence to automate prior authorization for services the feds say are often subject to fraud, waste and abuse.
WISeR will target over a dozen services, including image-guided decompression of the spine, epidural steroid injections for pain management (excluding facet joints), and percutaneous vertebral augmentation. However, 17 House Democrats are concerned WISeR will “limit beneficiaries’ access to care, increase burden on our…healthcare work force, and create perverse incentives to put profit over patients.”
Reps. Ami Bera, MD, D-Calif., Suzan DelBene, D-Wash., and colleagues voiced their concerns in a letter sent to the agency on Aug. 7.
“While prior authorization is often described as a cost-containment strategy, in practice it increases provider burden, takes time away from patients, limits patients’ access to life-saving care, and creates unnecessary administrative burden,” 17 representatives wrote to CMS Administrator Memet Oz, MD, on Aug. 7. “Many patients choose traditional Medicare because they know their care will be determined by their doctors and not by insurance companies.”
WISeR is slated to go into effect on Jan. 1 across New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington. The experiment will last six years, through 2031. 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.” Participating technology companies must utilize the expertise of clinicians, CMS emphasized, with final claim-denial decisions resting in the hands of physicians and “not machines.”
The Centers for Medicare & Medicaid Services announced WISeR days after touting a voluntary commitment from commercial insurers to reduce the burden of prior authorization. House lawmakers highlighted this questionable timing, noting that fee-for-service Medicare has “seldom” used prior authorization in the past. They questioned whether it’s wise to replace a “doctor’s medical knowledge with an algorithm designed to maximize care denials in order to increase profits.”
Representatives also highlighted previous abuse of prior authorization in Medicare Advantage. About 75% of rejected requests were overturned upon appeal, an HHS Office of Inspector General analysis found, “suggesting inappropriate initial denials were widespread.” And another 2022 OIG report further revealed Medicare Advantage plans frequently violate program rules in their deployment of prior authorization. It’s also “troubling,” they added, that the WISeR model will contract with Medicare Advantage plans, “the very entities that have abused” preauthorization.
Rep. Bera and colleagues posed a series of eight questions to CMS with a deadline of Sept. 1. They want to know what criteria were used to select states for the model, how entities will be chosen to participate, performance metrics, etc.
Meanwhile, a group of medical societies also voiced their opposition to WISeR in a separate message to Dr. Oz on Tuesday. Those signing the letter included the Medical Group Management Association, American Osteopathic Association, and the Congress of Neurological Surgeons.
“We do not believe that the WISeR Model includes sufficient transparency, accountability and oversight mechanisms to ensure that stakeholders have any real insight into how PA determinations are made,” the 12 groups wrote to CMS leadership on Aug. 12. “It is critical that, if CMS moves forward with this model, it should establish transparency requirements necessary to ensure that algorithms are not used to obfuscate denials of medically necessary care and should put in place a mechanism for regular audits of participating vendors.”
Others signing the congressional letter to CMS included Reps. Eleanor Holmes Norton, D-D.C., Linda Sánchez, D-Calif., Brad Schneider, D-Ill., Danny Davis, D-Ill., Don Beyer, D-Va., Nikki Budzinski, D-Ill. Jimmy Panetta, D-Calif., Jonathan Jackson, D-Ill., Marilyn Strickland, D-Wash., Terri Sewell, D-Ala., Marc Veasey, D-Texas, Judy Chu, D-Callif., Emily Randall, D-Wash., Raja Krishnamoorthi, D-Ill., and Mary Kaptur, D-Ohio.
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.