CMS to Medicare Recipients: Don’t Worry About These New Prior Authorizations
Thanks for reading! If you value this reporting and would like to help keep Work-Bites on the job AND GROWING, please consider becoming a “Work-Bites Builder” today for just $2.50 per month. Work-Bites is a completely independent 501c3 nonprofit news organization dedicated to our readers — and we need your support! Invite friends, family, and co-workers to subscribe to the Work-Bites Wake Up Call!!
New Yorkers march against massive budgetary cuts to Medicare and Medicaid on July 30. CMS, meanwhile, is introducing more prior authorizations to Traditional Medicare. Photo/Joe Maniscalco
By Joe Maniscalco
A few weeks ago, Work-Bites took a look at the white paper warning labor leaders about profit-driven Medicare Advantage plans and how they are just “another Wall Street privatization scheme of raiding public funds for private profit.”
In that same piece we noted how the Centers for Medicare and Medicaid Services [CMS]—under the auspices of celebrity doc turned CMS administrator Mehmet Oz—is set to introduce Medicare Advantage-style prior authorizations to Traditional Medicare in six states beginning Jan. 1.
Every since then we wanted to know more about the new pilot plan dubbed WISeR—Wasteful and Inappropriate Service Reduction—and if there is anything about it that could possibly justify the dumb name, or if the whole thing is just another ideological-fueled attempt to undermine Traditional Medicare.
Most of all, we wanted to know if subjecting Traditional Medicare to the same level of prior authorizations that are being used in profit-driven Medicare Advantage plans would be a desirable outcome of the WISeR model.
In other words, we wanted to know it that’s WISeR’s real intended purpose.
Well, it took almost three weeks to get an answer—maybe CMS needs to hire more people for it’s communications team—but we finally received some kind of response.
According to CMS, the WISeR model is not designed to replicate Medicare Advantage prior authorization policies in Traditional Medicare. Nope, the administration aiming to make Medicare Advantage the default health care plan for all Americans, says instead that the WISeR scheme is intended to be a “role model for other programs.”
What other programs CMS is talking about here remains unclear.
And we’re also told the WISeR model will be rigorously evaluated—with any future consideration of broader implementation requiring it demonstrate improved quality without increased spending, or reduced spending without compromising quality care.
The determination of whether or not it does those things, will rest with the CMS’ chief actuary. Paul Spitalnic is the agency’s current chief actuary, a role he’s had since 2013. Last month, Spitalnic helped introduce the 2025 Medicare Trustees Report which projects the Hospital Insurance trust fund—or Medicare Part A—will be depleted by 2033, three years earlier than previously projected.
We also questioned the WISeR model’s use of Artificial Intelligence in the prior authorization process and were told that any use of AI will be subject to strict oversight and that no request will be denied without review by an appropriate human clinician.
Does that assurance actually make anyone feel better?
Donald M. Berwick and Andrea Ducas also wrote in STAT last month how “the preauthorization CMS proposes to add to traditional Medicare is guaranteed to increase administrative costs. And it is bound to impede some high value care, too.”
Medicare expert Diane Omdahl also conceded in a piece for Forbes, “There is no way to know for sure whether WISeR will turn Original Medicare into a [Medicare] Advantage clone.”
As Rose Roach, national coordinator for the Labor Campaign for Single Payer and chair of Healthcare for All Minnesota, stressed to Work-Bites in July, it’s important to look at where the theory of prior authorization originated.
“It came from the insurance industry,” Roach said. “It came from the people who do everything they can to take more money in, and pay less money out.”
CMS says the WISeR model being rolled out in New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington as a voluntary program “will help reduce clinically unsupported care by working with companies experienced in using enhanced technologies to expedite and improve the review process for a pre-selected set of services that are vulnerable to fraud, waste and abuse.”
Roach, however, calls this crazy and “all part of the massive move to privatize everything—particularly inside of health care.”
“For them to take it to the level of not only injecting a private entity to take a look at Traditional Medicare diagnoses and claims—but then to say we're going to give you, basically, what I'm going to call a bounty for looking at that claim, and if you deny it, hey, good for us because now we've paid out less money—yeah, this is complete insanity.”
CMS insists the WISeR Model will “help ensure people with Medicare receive the most appropriate care that supports the best health outcomes while decreasing costs and easing administrative burden on providers and suppliers who go through the prior authorization process.”
Who are you gonna believe?