Medicare delays prior authorization pilot program for key interventional radiology service

“Our members report unclear standards, unreliable technology, minimal support and frequent delays that are disrupting care and forcing some patients to forgo treatment altogether,” the society added. “SIR is working with other medical societies to urge CMS to establish clear, standardized guidelines that protect patients and prevent unnecessary delays in care. We are also continuing to collect feedback from members to document the impact this model is having on patients’ access to care.”         

Inside Health Policy first reported news of the delay on April 3, noting that it came in response to push back from the field. In its notice, CMS said it is delaying implementation of prior authorization or prepayment review for these two services “to allow additional time for operational readiness.” It plans to disclose when the delay will end in a future notice. 

WISeR is focusing on over a dozen services Medicare says are often subject to fraud, also including epidural steroid injections for pain management, and percutaneous vertebral augmentation. The model is slated to last six years and spans New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington. Model participants—announced in November, including a radiologist-owned firm—are technology companies that use AI to help curb misuse of healthcare services. 

SIR also voiced physicians’ frustrations about WISeR in a recent letter to the head of Medicare. Penned as part of the Alliance of Specialty Medicine, radiologists and other clinicians raised concerns about the continued burden of prior authorization and other utilization management tactics. Along with SIR, other members of the coalition include the American Society of Echocardiography, American Urological Association and the Congress of Neurological Surgeons, altogether representing over 100,000 physicians and 15 societies. 

The alliance said it has received reports of WISeR increasing administrative and operational burdens on physician practices. This on top of the “already significant” utilization management requirements that are prevalent in the private sector, including Medicare Advantage. 

“Physicians are particularly concerned that the model introduces automated decision tools into an already complex utilization management environment,” SIR et al. wrote to Administrator Mehmet Oz, MD, MBA, on March 30. “While the Alliance strongly supports efforts to combat fraud, waste and abuse in the Medicare program, expanding prior authorization requirements within traditional Medicare—especially when supported by unproven artificial intelligence and other algorithmic technologies—risks delaying care for beneficiaries and raises.”