Lawmakers Aim to Block Expansion of Prior Auth in Traditional Medicare

 Lawmakers on Thursday explored the merits of a bill that would block the Centers for Medicare & Medicaid Services (CMS) from implementing a pilot program to test whether prior authorization can succeed in traditional Medicare.

During the House Energy and Commerce Health Subcommittee hearing, Rep. Greg Landsman (D-Ohio), who introduced the bill, said that it would prohibit the use of "AI to deny care in Medicare."

In June, CMS announced plans for an experimental Medicare model known as the Wasteful and Inappropriate Service Reduction (WISeR) Model, which would aim to help patients avoid unnecessary or inappropriate care, while also safeguarding taxpayer dollars.

The model will leverage artificial intelligence (AI) to expedite prior authorization processes for certain items and services "that have been identified as particularly vulnerable to fraud, waste, and abuse, or inappropriate use," according to CMS, including skin substitutes for wound care and knee arthroscopy for knee osteoarthritis, among others.

At its core, the program incentivizes for-profit companies to deny healthcare, since they receive a percentage of the money saved. That aspect of the program is "very perverse, very problematic," Landsman said. Moreover, there's little transparency into how the model would work.

Specifically, transparency is lacking on the "lines of code" used to decide what care is approved or denied, he explained, adding that it isn't clear whether the AI model is a "learning model" or whether it is "just denying what it's been told to deny."

David Lipschutz, an attorney and co-director of law and policy at the Center for Medicare Advocacy in Washington, D.C., during the hearing said, "I think the only thing that we do know is that these vendors that have been hired to participate in the WISeR model ... have a financial stake in denying care. They benefit when care is withheld, which is exactly the wrong model to be using in healthcare, particularly with Medicare."

The model will be piloted in only six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington.

Curiously, CMS held a roundtable discussion with insurers shortly before their June announcement, after which it said that it had secured a pledge to fix the "broken prior authorization system" in Medicare Advantage plans.

For the initial pilot program, the agency has chosen to target "low-hanging fruit," said Landsman, noting that he suspects the agency hopes no one will notice when the model moves away from items that are easier to deny coverage for to "the kind of healthcare decisions that will lead to life-and-death decisions."

"And that is why this is being called by many, many people 'AI death panels,' because AI is going to make decisions on whether or not somebody gets the healthcare they need, and that decision may lead to that person losing their life," he added.

Ranking member of the full committee Rep. Frank Pallone (D-N.J.) voiced support for the bill, saying that the WISeR model "threatens beneficiaries' access to timely and necessary medical care."

However, Committee Chairman Rep. Brett Guthrie (R-Ky.) appeared hesitant to fully endorse Landsman's bill, noting that he met with providers who shared stories of approvals and denials and "from what I could tell, there was little difference."

But "we do have to be concerned about people setting up entities and taking advantage of not having any [prior] authorization whatsoever," he said. "There's ways to fix it. And hopefully ... all of us can work together to figure that out, because we want patients to get the care that they need, that the providers determine they need."

He said that there will be opportunities to discuss these issues when the full committee meets with insurance CEOs on Jan. 22.

Other legislation discussed at the hearing included a bill to extend funding for outreach to seniors and create more transparency around the available benefits in Medicare Advantage plans; a bill to preserve Medicare patients' access to home infusion services; and a bill to ensure better data collection for clinical diagnostic laboratory test costs, with the goal of preventing looming cuts in payment.

https://www.medpagetoday.com/publichealthpolicy/medicare/119366