Medicare enrollees in Washington may soon need to get additional approval before undergoing some medical procedures, under a controversial new program the federal government will test in a half-dozen states.\u202f\u00a0<\/p>\n
The six-year pilot program begins Jan. 1 in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington, and will rely on artificial intelligence to help decide whether certain care is eligible for coverage.\u202f\u00a0<\/p>\n
It\u2019ll be voluntary for doctors to participate, but critics still see the initiative as a sign of the Trump administration creeping toward Medicare privatization and are unsettled by the use of AI.\u00a0<\/p>\n
\u201cThis just is unfortunate and surprising news,\u201d said Dr. Matt Hollon of the Washington State Medical Association. \u201cPatients expect their care to be guided by doctors, not insurance companies or automated systems.\u201d\u00a0<\/p>\n
The U.S. Centers for Medicare and Medicaid Services says the goal is to root out fraud, waste and abuse with Medicare, the federal program that provides health coverage to people older than 65 and younger people with disabilities.\u00a0<\/p>\n
Patient advocates, doctors, hospitals and lawmakers in Washington state argue that current forms of the process, known as prior authorization, have been frustrating and resulted in barriers to care.\u202f\u00a0<\/p>\n
And they say they\u2019ve gotten few details from the feds on the rapid rollout.\u202f\u00a0<\/p>\n
For one, it\u2019s unclear why Washington was picked.\u202f\u00a0<\/p>\n
A Centers for Medicare and Medicaid Services spokesperson said the state\u2019s inclusion is reflective of the agency\u2019s\u202f\u201cgoal of testing across diverse practice environments to ensure a reliable and valid model test.\u201d Washington has about 1.6 million Medicare beneficiaries, about half of whom are enrolled in traditional Medicare and the other half in Medicare Advantage, according to the state.\u00a0<\/p>\n
The\u202fnew model<\/a>, known as Wasteful and Inappropriate Services Reduction, or WISeR, will work with third-party companies deploying artificial intelligence to decide if traditional Medicare enrollees qualify for certain outpatient procedures. Health care professionals will have to review any denials the AI technology makes.\u202f\u00a0<\/p>\n Procedures covered are those the federal government sees as too costly for the resulting medical benefit, or lack thereof. They include skin and tissue substitutes, impotence treatment, deep brain stimulation, cervical fusion, and knee arthroscopy for osteoarthritis,\u202famong others<\/a>. Spending on expensive skin substitutes, for example, has\u202fsurged in recent years<\/a>\u202feven as their clinical value is questioned.\u00a0<\/p>\n The CMS spokesperson said the objective \u201cis to help patients avoid unnecessary, inappropriate procedures across a narrow set of services.\u201d But critics worry this opens the door to expanding the practice to other procedures, possibly during the six-year pilot. They also contend it could be a step toward privatization.\u202f\u00a0<\/p>\n Sen. Patty Murray, D-Wash., called it a \u201cbackdoor move by Republicans to privatize Medicare and let AI decide who deserves health care.\u201d\u00a0<\/p>\n \u201cI will be opposing it every way I can in the Senate,\u201d Murray said in a statement.\u202f\u00a0<\/p>\n The third-party companies involved will be compensated with a share of the savings they generate, stoking fears the decision-makers will be incentivized to deny approval.\u00a0<\/p>\n \u201cThe use of AI is looking at this sort of aggregation of data, right? That doesn\u2019t apply to individual patients and may not recognize an individual circumstance, and then they get paid to deny care,\u201d said Hollon, a physician in Spokane. \u201cIt\u2019s antithetical to health care.\u201d\u00a0<\/p>\n The CMS spokesperson said companies will face penalties for wrongful denials and slow decisions.\u202f\u00a0<\/p>\n Doctors will volunteer to submit prior authorization requests. If they don\u2019t, their insurance claims will be subject to the traditional pre-payment review. The incentive for physicians is knowing that their care will be compensated upfront, instead of learning after the fact that it\u2019s not covered.\u202f\u00a0<\/p>\n Jeb Shepard, policy director for the medical association, sees this as the \u201cfirst foray\u201d into prior authorization for traditional Medicare, and it may not always be voluntary.\u00a0<\/p>\n How it has worked previously\u00a0<\/p>\n Medicare Advantage, which includes Medicare-approved plans from private insurers, already deploys prior authorization, as opposed to traditional Medicare, where it has rarely been required.\u202f\u00a0<\/p>\n Most denials for prior approval made under Medicare Advantage are\u202foverturned upon appeal<\/a>. But some patients don\u2019t even know they can appeal, and abandon the care.\u202f\u00a0<\/p>\n Scrutiny over prior authorization increased after the killing last year of UnitedHealthcare CEO Brian Thompson, whose company contributed to a surge in Medicare Advantage denials.\u202f\u00a0<\/p>\n The companies participating in the new process will likely overlap with those already involved in Medicare Advantage\u2019s unpopular review system.\u202f\u00a0<\/p>\n Just days before announcing the WISeR model in June, Health and Human Services Secretary Robert F. Kennedy Jr. and CMS Administrator Mehmet Oz\u202ftouted a pledge<\/a>\u202ffrom industry leaders to streamline and reduce prior authorization in Medicare Advantage. Insurers said at the time they hoped to decide 80% of requests within moments by 2027, erasing the delays that have frustrated patients and doctors.\u00a0<\/p>\n \u201cHospitals do not oppose the idea of making sure that the care that\u2019s provided is care that is needed,\u201d said Taya Briley, general legal counsel at the Washington State Hospital Association. \u201cWhat hospitals do get concerned about is cumbersome processes that essentially just slow the system down, make it so that it\u2019s hard for patients to get the care they need, make it hard for hospitals to get paid.\u201d\u00a0<\/p>\n Dr. Bindu Nayak, an endocrinologist at Confluence Health in Wenatchee, said \u201cprior authorization is part of every physician\u2019s daily work, and it adds a lot of time.\u201d This is time that could instead be spent working directly with patients, she added.\u00a0<\/p>\n Meanwhile, the Statewide Health Insurance Benefits Advisors program manager at Washington\u2019s Office of the Insurance Commissioner thinks WISeR could be a \u201cnet positive.\u201d\u00a0<\/p>\n \u201cWe\u2019ll have a more definitive yes or no [if] Medicare is going to pay for it faster if the pilot works the way that it\u2019s supposed to,\u201d said program manager Tim Smolen. \u201cSo there should be fewer surprises for providers and for beneficiaries.\u201d\u00a0<\/p>\n Looking for answers\u00a0<\/p>\n Last month, U.S. Rep. Suzan DelBene, D-Medina,\u202fled a letter<\/a>\u202fwith more than a dozen of her colleagues asking Oz myriad questions about the pilot. Washington Reps. Marilyn Strickland, D-Tacoma, and Emily Randall, D-Bremerton, also signed on.\u00a0<\/p>\n As of Monday, Oz hadn\u2019t responded.\u202f\u00a0<\/p>\n \u201cThis should be a bipartisan issue. The states are across the country,\u201d DelBene said in an interview. \u201cThere should be concern about making sure that people have access to care in all these states and understand exactly how the models work, why it\u2019s set up this way, what their goals are.\u201d\u00a0<\/p>\n An AARP spokesperson said the organization is \u201cwatching carefully\u201d the implementation of WISeR.\u00a0<\/p>\n \u201cWe are deeply concerned about persistent reports of fraud and abuse of Medicare that are draining the system of much-needed resources,\u201d the spokesperson said in an email. \u201cAt the same time, the health care of older Americans must always come first, and nobody should be denied legitimate treatments they need.\u201d\u00a0<\/p>\n This year, Washington state lawmakers\u202fconsidered legislation<\/a>\u202fadding oversight to the use of prior authorization and limiting the role of artificial intelligence. The measure didn\u2019t make much progress in the Legislature, but will come back in 2026.\u00a0<\/p>\n