Medicare’s WISeR Program: A Look into Delays and Concerns
Early hospital data presented on Capitol Hill reveals significant delays in care for Medicare patients, attributed to a federal testing program. This initiative, focusing on the automated evaluation of prior authorization claims, is under scrutiny for its potential impact on patient care.
Introduction to the WISeR Model
The Wasteful and Inappropriate Services Reduction Model (WISeR) is a one-year pilot project initiated by the Centers for Medicare & Medicaid Services (CMS) Innovation Center (CMMI). Launched on January 1, it spans six states and aims to address fraud, waste, and abuse within Medicare, particularly for services considered “low value” or prone to misuse. This effort aligns with the previous administration’s goals of enhancing Medicare’s efficiency through artificial intelligence (AI).
Initial Feedback and Reported Delays
However, the program has sparked concerns from hospitals, providers, and lawmakers. A report by Sen. Maria Cantwell (D-Wash.), based on data from hospitals affiliated with the Washington State Hospital Association, highlights procedure completion times that have significantly increased post-WISeR implementation. According to the report, hospital procedures that previously took around two weeks for approval now require four to eight weeks, exacerbating patient discomfort and health conditions.
The University of Washington Medical System reported a drastic increase in approval times, with urgent approvals extending from one day to 15-20 days. This delay affected nearly 100 patients awaiting epidural steroid injections, underscoring the model’s impact on patient care.
Patient Impact and Legislative Response
In 2024, over 18,600 Washington state residents, now subject to prior authorization under WISeR, are experiencing these delays. Sen. Cantwell raised these issues during a budget hearing with Health and Human Services Secretary Robert F. Kennedy Jr., expressing concerns that AI might be misused as a denial tool within CMS. Cantwell emphasized the need for transparency and questioned how AI decisions are made, to which Kennedy assured that human oversight is integrated into the system.
Concerns Over AI and Administrative Burdens
Beyond delays, the report highlights increased administrative burdens and potential conflicts of interest. The model’s structure, which rewards third-party administrators for denied claims not overturned, could incentivize profit-driven decisions. Tammy Buyok of Yakima Memorial Hospital expressed concerns about potential barriers created by for-profit tech companies intervening in care decisions.
Various organizations, including the American Hospital Association and the American Medical Association, have voiced objections to the WISeR model. They warn of the potential for misaligned incentives and extended prior authorization requirements in traditional Medicare, advocating for a more phased approach.
Public and Industry Reactions
As CMS explores expanding prior authorization in traditional Medicare, it faces public and legislative opposition. A KFF survey from January revealed that 32% of patients consider preauthorization a significant burden, surpassing other healthcare navigation challenges. This sentiment has led major insurers to reconsider their prior authorization practices, despite ongoing challenges reported by provider organizations.
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