House Democrats have recently introduced a bill aimed at repealing a controversial CMS innovation center payment model that incorporates artificial intelligence-backed prior authorization for certain services in Medicare. The model, known as WISeR (Wasteful and Inappropriate Service Reduction), is set to roll out in six states starting in January, with the CMS announcing the health technology companies that will administer the program.
The bill, named the Seniors Deserve SMARTER (Streamlined Medical Approvals for Timely, Efficient Recovery) Care Act, was put forward by a group of Democrat representatives, including Rick Larsen, Suzan DelBene, Kim Schrier, Greg Landsman, Ami Bera, and Mark Pocan. The lawmakers argue that the implementation of prior authorization through AI technology will result in increased bureaucracy and reduced access to care for Medicare seniors. Rep. Mark Pocan went as far as to say that the requirement of prior authorization could have fatal consequences for seniors, labeling the use of AI in decision-making as reckless.
The WISeR model, introduced by the Center for Medicare and Medicaid Innovation, aims to use AI-backed prior authorization for specific services like skin and tissue substitutes and electrical nerve stimulator implants. The CMS believes that this approach will help identify unnecessary care, leading to cost savings for both patients and the government. The private companies partnering with the CMS for this initiative will receive a portion of the savings generated as a result of their efforts.
Lawmakers have expressed concerns about the WISeR pilot, highlighting potential negative impacts on health outcomes for Medicare seniors and the healthcare workforce. They are now pushing for the complete repeal of the model, emphasizing the importance of medical decisions being made by healthcare professionals rather than algorithms designed to cut costs.
The debate around prior authorization is not new, with providers arguing that it adds administrative burden and delays essential care, while payers defend it as a tool to prevent unnecessary spending. The Trump administration has taken steps to limit prior authorization, with insurers pledging to reform the process and reduce the number of claims requiring prior approval.
The use of AI in medical claims review has also raised red flags among lawmakers, with concerns about potential increases in coverage denials. Senator Richard Blumenthal recently addressed major Medicare Advantage insurers regarding their use of AI technology in coverage decisions.
As the healthcare landscape continues to evolve, the debate over the role of AI in decision-making processes and the impact of prior authorization on patient care remains a topic of contention among policymakers, providers, and payers. It is clear that finding a balance between efficiency, cost-effectiveness, and quality of care will be crucial in shaping the future of healthcare delivery in the United States.
