Medicare cost-cutting initiative targets ‘wasteful, inappropriate’ interventional radiology services
A Centers for Medicare & Medicaid Services cost-cutting initiative announced on Friday will target allegedly unnecessary outpatient services delivered by interventional radiologists and other physicians.
CMS next year is rolling out the Wasteful and Inappropriate Service Reduction (or “WISeR”) Model across select states. The agency is partnering with technology vendors, who will utilize artificial intelligence to root out requests for services the feds say are often subject to fraud, waste and abuse.
Beginning Jan. 1, WISeR will be rolled out across New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington in traditional Medicare. It 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. The latter, also known as PVA, uses X-ray guidance to inject bone cement into the fractured vertebrae (a minimally invasive procedure also recently targeted by Elevance Health).
“Low-value services, such as those of focus in WISeR, offer patients minimal benefit and, in some cases, can result in physical harm and psychological stress,” Abe Sutton, director of the CMS Innovation Center, said in a statement June 27. “They also increase patient costs, while inflating healthcare spending.”
The American College of Radiology could not provide comment on the care model by end of day Tuesday, while the Society of Interventional Radiology said it was still formulating an opinion.
“SIR is aware of the notice and is currently reviewing the content in coordination with partner organizations to provide feedback to CMS and appropriate guidance to our members,” a society representative said July 1.
Interventional radiologists criticized the CMS proposal when asked for their reaction on social media.
“Requiring approval for vertebral augmentation is nonsensical. This will definitely cause excess morbidity and mortality,” Douglas Beall, MD, an Oklahoma-based IR specialist, told Radiology Business.
“This is a true shame that they consider services such as vertebral augmentation ‘low value,’” added Kavi Devulapalli, MD, an interventional specialist based in Missouri. “It is becoming so difficult to practice medicine. The hits keep on coming and it seems to me there is little we can really do about it. I fear for the future of healthcare in this country and wonder if there will be any competent doctor to take care of me down the road.”
“Explain to me like I’m 5: What will I need to do to get Medicare approval for a kyphoplasty once this takes effect? Vertebral augmentation [patients] are my happiest [patients],” added another X.com user, who uses the handle “Swamp Possum.”
Other impacted services include skin and tissue substitutes, electrical nerve stimulator implants and arthroscopy for knee osteoarthritis. However, the model excludes several clinical scenarios such as inpatient stays, emergency care, or instances when prior authorization may pose “substantial risk to patients if significantly delayed.” Technology companies tasked with handling these expedited reviews must utilize the expertise of clinicians, the agency emphasized. Final claim-denial decisions will rest in the hands of docs and “not machines,” the announcement added.
CMS will test the model over six years beginning in 2026. Companies that have experience implementing technology-enhanced prior authorization with other payers will serve as the model’s primary participants. The agency said it chose the six states because they have adequate volume to measure the model’s impact, geographic diversity, and currently provide coverage for skin and tissue substitutes, among other factors.
Participants’ payments will be adjusted based on their performance against established measurements. This will include the ability to support “faster decision-making for providers and suppliers” while improving the prior authorization experience for both docs and their patients. Officials emphasized that WISeR will not change Medicare coverage nor payment criteria, with beneficiaries still free to seek care from their physician of choice. CMS may eventually modify the model to allow providers with “strong compliance records” to qualify for exemptions from WISeR review.
The announcement comes after CMS recently touted a voluntary commitment from major commercial insurers to ease the burden of prior authorization. On Monday, the Medical Group Management Association said it supports efforts to tackle waste, fraud and abuse in Medicare. However, MGMA is concerned this model will worsen the administrative burden on physicians while undoing any positive gains from the prior authorization pledge.
“The announcement of this [Medicare] Part B model seems to contradict the administration's recent commitments to ease the burden of prior authorization. We look forward to working with [the Center for Medicare and Medicaid Innovation] and the administration on efforts to reduce waste and ensure they do not come at the cost of greater administrative burdens and interference with clinical decision-making,” Anders Gilberg, senior VP of government affairs for MGMA, which represents over 15,000 medical group practices across radiology and other specialties, said in a statement June 30.
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.