Photo: Thomas Barwick/Getty Images
House Democrats on Friday introduced legislation to get rid of the WISEeR model for prior authorization in traditional Medicare.
Representatives Rick Larsen (WA-02), Suzan DelBene (WA-01), Kim Schrier, MD (WA-08), Greg Landsman (OH-01), Dr. Ami Bera (CA-06) and Mark Pocan (WI-02) introduced the Seniors Deserve SMARTER (Streamlined Medical Approvals for Timely, Efficient Recovery) Care Act, which would repeal the Centers for Medicare and Medicaid Services’ Wasteful and Inappropriate Service Reduction (WISeR) model.
The model would hire private companies to use artificial intelligence to automate prior authorization. The vendors would be compensated based on a share of “averted expenditures,” rewarding participants based on the volume or cost of care they deny, the representatives said in a press release.
WHY THIS MATTERS
CMS announced the six-year model in June. WISeR is scheduled to begin in 2026 in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington.
In October, the American Hospital Association voiced “substantial concerns” about the model in a letter to CMS.
“We have substantial concerns regarding the participating vendor payment structure, which 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. Such a structure creates a perverse incentive to deny care that otherwise may be appropriate, as vendors may increase their profits by denying care,” the AHA said in the letter to Abe Sutton, deputy administrator and director at the Center for Medicare and Medicaid Innovation.
The AHA urged CMS to delay implementation by at least six months.
THE LARGER TREND
In recent years, the U.S. Department of Health and Human Services revealed that Medicare Advantage plans ultimately approved 75% of requests that were originally denied, the representatives said in the press release. A 2022 HHS report further revealed that Medicare Advantage plans frequently violated Medicare coverage rules in their use of prior authorization.
Nearly a third of physicians report that prior authorization has led to a serious adverse health event for a patient in their care, they said.
The legislation is endorsed by the American Podiatric Medical Association, Physicians for a National Health Program, The Center for Health and Democracy, Social Security Works, Just Care USA, Washington State Medical Association, Washington State Hospital Association, Texas Medical Association, Washington Community Action Network, Healthcare is a Human Right Coalition, Puget Sound Advocates for Retirement Action, Health Care for All – Washington, and Social Security Works WA.
ON THE RECORD
“As a doctor and former Chief Medical Officer of Sacramento County, I’ve seen how harmful prior authorization can be when it delays or denies necessary care for patients,” said Dr. Ami Bera, one of the bill’s sponsors. “The WISeR model takes that a step further by financially rewarding companies for denying care through so-called ‘averted expenditures.’ That creates a dangerous incentive to put profits ahead of patients’ health. These decisions should be made by doctors, not by algorithms designed to cut costs.”
Email the writer: SMorse@himss.org