The U.S. Centers for Medicare & Medicaid Services (CMS) is exploring prior authorizations within traditional Medicare for some services.
The Center for Medicare & Medicaid Innovation is launching a demonstration program called the Wasteful and Inappropriate Service Reduction Model, aimed at applying advanced technology to prior authorization processes within traditional Medicare.
“WISeR will harness enhanced technologies like Artificial Intelligence (AI) and Machine Learning (ML) to streamline the review process for certain items and services that are vulnerable to fraud, waste and abuse, helping people with Medicare receive safe and appropriate care and protecting federal taxpayers,” CMS indicated in a fact sheet. “The model is voluntary and will run for six performance years from Jan. 1, 2026 to Dec. 31, 2031.”
The program will have four principal goals:
- Focus health care spending on services that will improve patient well-being
- Apply commercial payer prior authorization processes that may be faster, easier and more accurate
- Increase transparency of existing Medicare coverage policy
- De-incentivize and reduce use of medically unnecessary care
WISeR will exclude inpatient-only services, emergency services and services that would pose a substantial risk to patients if substantially delayed. All recommendations for non-payment will be determined by appropriately licensed clinicians who will apply standardized, transparent and evidence-based procedures to their review, CMS indicated.
The agency will adjust payments for providers that achieve effective results.
“Participants will be rewarded based on the effectiveness of their technology solutions for reducing spending on medically unnecessary or non-covered services,” CMS reported. “For each selected service, participants will receive a percentage of the reduction in savings that can be attributed to their reduction of wasteful or inappropriate care.”
The payment adjustments will be based on factors such as process quality, the number of non-affirmations and favorable appeal decisions, volume of requests processed, as well as provider/supplier and beneficiary experience. Timeliness of response is another criteria, as is the clarity of explanation of request determinations and clinical quality outcomes.
