Push to block ‘WISeR’ Medicare prior authorizations dies in the Senate
An attempt by a group of Democrats in the U.S. Senate to end a controversial program by the Centers for Medicare & Medicaid Services (CMS) that uses artificial intelligence to effectively add a prior authorization process to traditional Medicare has been snuffed out after a 46-50 vote on Thursday.
The result means the Wasteful and Inappropriate Service Reduction (WISeR) model will remain in place for now, forcing six states to pilot the use of AI to automate the approval and denial of claims for patient care billed to Medicare, a process typically only used by privatized versions of the program, dubbed Medicare Advantage or Medicare Part C.
Under WISeR, CMS has partnered with private companies that will earn incentive payments based on their ability to root out what CMS believes to be waste in the Medicare reimbursement pipeline, where patient care is being delivered without medical need.
Opponents of the program are worried the chaos surrounding prior authorizations—where essential care is delayed and denied inconsistently—will now simply come to traditional Medicare, putting the health of seniors at risk, in this case for the benefit of for-profit tech companies.
The list of vendors working as part of the WISeR pilot includes Cohere Health, Genzeon Corporation, Humata Health, Innovaccer, Virtix Health and Zyter.
A group of Democrat senators, including Ron Wyden (D-OR), Maria Cantwell (D-WA), Richard Blumenthal (D-CT) and Kirsten Gillibrand (D-NY), were the primary backers of an attempt to use the Congressional Review Act to press pause on WISeR.
The act allows Congress to step in when it believes federal agencies are overstepping their authority.
“Seniors paid into Medicare out of every paycheck during their working years, and they did so with an expectation they would have an ironclad guarantee of affordable healthcare,” Wyden told the Senate on Thursday, before the measure was struck down. “Today, seniors in six states across America are discovering that care their doctor has recommended for them has been slowed or halted by a shadowy, AI-driven third party.”
Those in opposition to using the Congressional Review Act were all Republicans, including Sen. Mike Crapo (R-ID), who argued that the pilot should be allowed to play out, to see if it really does save the federal government money without causing undue harm to seniors.
“Every member of this body agrees that patients should have access to high-quality care, providers deserve predictable payment for services, and avoidable waste, fraud and abuse in Medicare should be stopped,” he said. “Ending this pilot program prematurely will deprive CMS of a useful tool to accomplish each of those goals.”
The 46-50 vote split cleanly along party lines.
AI prior auths face defunding, lawsuit
The WISeR AI prior authorization program still faces pressure from lawmakers and policy advocates alike. In the U.S. House of Representatives, a bipartisan committee voted unanimously in June to pull federal funding from the initiative as part of a federal budget amendment.
It’s unclear if the amendment will survive the House, let alone the Senate, intact.
CMS may still be forced to answer some tough questions about WISeR’s methodology and effectiveness, as the agency is being sued by the Electronic Frontier Foundation (EFF), a nonprofit digital rights advocacy group that claims the agency has failed to respond to a Freedom of Information Act (FOIA) request, seeking details on how the AI algorithms used for Medicare claims denials work.
That lawsuit, filed in March, has yet to move forward.
The six states where WISeR is deployed include New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington. If deemed to be successful, it could be rolled out nationwide.
Chad is an award-winning writer and editor with over 15 years of experience working in media. He has a decade-long professional background in healthcare, working as a writer and in public relations.