The state is part of a pilot program that will incentivize reviewers who deny certain services deemed wasteful or inappropriate.
DALLAS — I know for some people, Medicare open enrollment time (which is happening now) can seem like a dreaded medical procedure: You know you need to get it done, but you don’t really want to do it.
Maybe this will make you feel better. As you look at all the options with Medicare Advantage and the different decisions with Original Medicare, some simple advice from Carl Burlbaw, the senior insurance counselor at the Senior Source in Dallas: “Just focus on the priorities of which plan allows you to see your doctors, which plan covers your prescriptions in the most cost-effective way, and then what other benefits you can add to those other two priorities.”
As you are contemplating all that and looking at all the options, remember you have until Dec. 7 to figure it out and get signed up. Medicare expert Scott Chase says, “I remember when I signed up for Medicare, it took me three or four days. But as I went along, I got more comfortable on the process. So, testing it is a good idea. You don’t have to sign up the first time you use the system.”
Some changes this year
It’s always hard when you’ve had the freedom to do something and then all of a sudden you have to start asking for permission to do it. But that is about to happen under a new program that will focus on Original Medicare in six states, including Texas. The program is specifically scrutinizing these 17 procedures.
Starting next year, those will require pre-authorization. If you don’t get that approval ahead of time, your claim will be reviewed after the fact if you had one of those 17 procedures, which Chase says, “Were picked because they were overused. And so, they felt like getting pre-authorization was going to be a way to cut back on overuse.”
Indeed, part of the reason Texas is one of the handful of states included in this rollout is that this state had among the highest volume and highest claim amounts paid for the procedures being flagged for extra scrutiny under a new program the government calls WISeR, which stands for Wasteful and Inappropriate Services Reduction.
If you go through this process, as a patient, Burlbaw says you may have to be more…patient.
“You know, I think for the patient, what it’s going to mean is there’s probably more work on the front end before actually getting the procedure done, certainly by the doctor,” Burlbaw said. “And then…probably a longer wait time before the procedure can actually be completed for the patient.”
AI-assisted denials and denial incentives
It’s not just humans who will review your procedure to see if it’s necessary. Artificial intelligence and algorithms will be used to review these claims as well. But a person will have to sign off if the decision is to deny you.
You should also know this: The services being used for this “Will be rewarded…will receive a percentage” of the savings they create by denying what is deemed “wasteful or inappropriate care.”
Importantly, though, those reviewers will be audited and can be financially penalized if they get it wrong. And it gets worse for them if they keep getting it wrong, “Further, participants who have a high rate of inaccuracy may be terminated from the model”. And remember, you will also be able to appeal their decisions. The WISeR program will not apply to Medicare Advantage plans.