House Democrats Propose Bill to Repeal AI-Backed Prior Authorization in Medicare
Introduction of the WISeR Model
On Friday, House Democrats unveiled a bill aimed at repealing a payment model from the Centers for Medicare and Medicaid Services (CMS) that incorporates artificial intelligence for prior authorization on certain Medicare services. The model, known as the Wasteful and Inappropriate Service Reduction (WISeR), is set to launch in six states starting in January. The CMS recently announced which health technology firms will oversee this new initiative.
Concerns from Democratic Representatives
The six Democratic representatives who sponsored the legislation express concern that the WISeR model will introduce additional bureaucracy and restrict access to care for seniors on Medicare. Representative Mark Pocan of Wisconsin stated, “It is not an exaggeration to say that the requirement of prior authorization for traditional Medicare services will kill seniors. Not only that, but the use of AI in determining whether or not treatment is necessary is extremely reckless.”
Details of the SMARTER Care Act
The proposed legislation, titled the Seniors Deserve SMARTER (Streamlined Medical Approvals for Timely, Efficient Recovery) Care Act, was introduced by Representatives Rick Larsen, Suzan DelBene, Kim Schrier, Greg Landsman, Ami Bera, and Pocan. This initiative follows the announcement of the WISeR model by the Center for Medicare and Medicaid Innovation, a body formed under the Affordable Care Act to evaluate new payment and care delivery methods for governmental healthcare programs.
Changes to Traditional Medicare Authorization
Traditionally, Medicare employs prior authorization selectively, allowing physicians to obtain approval from insurers before providing specific services or medications. However, the WISeR model expands this practice by collaborating with private firms to implement AI-driven prior authorization for various services, including skin and tissue substitutes and electrical nerve stimulator implants. The CMS contends that this model will help eliminate unnecessary care and reduce costs for both patients and the government.
Involvement of Health Technology Companies
The companies engaged with the Center for Medicare and Medicaid Innovation (CMMI) include Cohere Health in Texas, Genzeon in New Jersey, Humata Health in Oklahoma, Innovaccer in Ohio, Virtix Health in Washington, and Zyter in Arizona. These firms will receive a share of the savings generated from the implementation of the WISeR model, as stated by the CMS.
Democratic Concerns About Health Outcomes
Democrats have previously raised alarms regarding the potential negative impacts of the WISeR pilot. A letter sent to the CMS this summer highlighted concerns that the model might exacerbate health outcomes for Medicare seniors and place additional strain on the healthcare workforce. Lawmakers are now advocating for the complete repeal of the WISeR model.
Impact of Prior Authorization on Patient Care
Ami Bera, a physician and former Chief Medical Officer of Sacramento County, criticized the model, asserting that prior authorization often delays or denies essential patient care. He emphasized that the WISeR model incentivizes companies to deny care under the guise of ‘averted expenditures,’ prioritizing profits over patient health. “These decisions should be made by doctors, not by algorithms designed to cut costs,” Bera concluded.
CMS’s Position on Coverage Denials
The CMS has maintained that final determinations on coverage denials will be conducted by licensed clinicians. Additionally, inpatient-only services, emergency services, and treatments that pose significant risks if delayed are excluded from the model’s purview.
Debate Surrounding Prior Authorization
The practice of prior authorization remains controversial. Providers argue that it imposes excessive administrative burdens and delays necessary medical care, while payers defend it as a crucial method for preventing low-value spending. The previous Trump administration even sought to reform the prior authorization process by rallying large insurers to reduce the number of claims requiring such approvals.
Concerns Regarding AI in Medical Claims
Lawmakers have expressed apprehension over the role of AI in medical claims review. A report from the Senate Permanent Subcommittee on Investigations revealed that significant Medicare Advantage insurers were employing predictive technology to increase denials for post-acute care. Recently, Senator Richard Blumenthal of Connecticut reached out to major Medicare Advantage payers, including CVS Health, UnitedHealthcare, and Humana, concerning their use of AI for coverage decisions.