The state is part of a pilot program that will incentivize reviewers who deny certain services deemed wasteful or inappropriate.<\/p>\n
DALLAS \u2014 I know for some people,\u00a0Medicare open enrollment<\/a> time (which is happening now) can seem like a dreaded medical procedure: You know you need to get it done, but you don\u2019t really want to do it.<\/p>\n 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: \u00a0\u201cJust 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.\u201d<\/p>\n 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, \u201cI 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.\u201d<\/p>\n
It\u2019s always hard when you\u2019ve 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\u00a0under a new program<\/a> that will focus on Original Medicare in six states, including Texas. The program is specifically scrutinizing\u00a0these 17 procedures<\/a>.\u00a0<\/p>\n Starting next year, those will require pre-authorization. If you don\u2019t 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, \u201cWere picked because they were overused. And so, they felt like getting pre-authorization was going to be a way to cut back on overuse.\u201d<\/p>\n 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\u00a0WISeR<\/a>, which stands for Wasteful and Inappropriate Services Reduction.<\/p>\n If you go through this process, as a patient, Burlbaw says you may have to be more\u2026patient.\u00a0<\/p>\n \u201cYou 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\u2026probably a longer wait time before the procedure can actually be completed for the patient.\u201d<\/p>\n
It\u2019s not just humans who will review your procedure to see if it\u2019s 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.<\/p>\n
\nSome changes this year <\/p>\n
\nAI-assisted denials and denial incentives <\/p>\n