In October, CMS announced the launch of a new prior authorization demonstration that would introduce new requirements for select services.
This comes just four months after news of an agreement between CMS and Medicare Advantage plans to lessen the use of prior authorization, reflecting a conflicted approach by the government when it comes to prior authorization, Medpage Today reported Dec. 29.
1. The agreement between CMS and insurers including American’s Health Insurance Plans, the Blue Cross Blue Shield Association, CareFirst BlueCross BlueShield, Centene Corporation, Cigna, Humana, Kaiser Permanente and UnitedHealthcare. The insurers pledged to standardize electronic prior authorization submissions, reduce the volume of medical services subjected to prior authorizations, implement real-time approvals for most requests by 2027 and ensure that medical professionals review all clinical denials.
2. That agreement came on the heels of other regulatory changes that were already in the works. This includes a ruling by CMS in 2023 related to prior authorizations’ interoperability as well as other regulations that were included as part of the Medicare Advantage and PArt D final rule, according to the Medpage report.
3. While cuts to prior authorization may be underway for Medicare Advantage plans, its use is being expanded in traditional Medicare. The new demonstration project announced by CMS, the Wasteful and Inappropriate Service Reduction Model (WISeR), aims to “partner with companies specializing in enhanced technologies to test ways to provide an improved and expedited prior authorization process.”
4. The WISeR Model will essentially test whether new technologies, including AI, can be used to expedite the prior authorization process for items and services that “have been identified as particularly vulnerable to fraud, waste, and abuse, or inappropriate use. While the model is voluntary, limited to six states and omits emergency and inpatient-only services, “providers and suppliers in the assigned regions will have the choice of submitting prior authorization requests for selected items and services or their claim will be subject to pre-payment medical review. This means that claims for affected services will be reviewed regardless.
5. The model received pushback from lawmakers, including Representative Suzan DelBene, a Democrat from Washington. She told Medpage that the Trump administration “is trying to take a victory lap on insurers streamlining prior authorization in Medicare Advantage, and in the other instituting the same delay tactics in traditional Medicare.”
6. Under the model, vendors will be paid a share of the savings generated by the claims they deny.
“It’s not the prior authorization that’s the problem; it’s the vendors who are conflicted,” Marsha Simon, PhD, adjunct professor of health policy at George Washington University in Washington, D.C., told the publication. Another source told Medpage that some of the vendors have “financial and strategic investors tied to Medicare Advantage plans; that’s where we’re concerned about potential indirect conflict-of-interest concerns.”
7. While the program is set to launch Jan. 1, physicians in affected states have “heard very little from the vendors about how the program will work,” according to Medpage. CMS told the publication that it is “actively working with WISeR participants and CMS Medicare Administrative Contractors (MACs) on readiness. WISeR participants, MACs, and CMS have been conducting education and outreach to providers in selected states and will continue to do so as the model begins. CMS will continue to work with providers and participants to ensure any issues are rapidly identified and resolved.”
