New Medicare AI model reportedly causing care delays and denials

As we age, navigating healthcare can become increasingly complex. For many, Medicare provides a vital safety net. However, a new AI-driven system introduced this year by the Centers for Medicare & Medicaid Services (CMS) is reportedly creating hurdles, causing delays and denials for certain medical procedures in Original Medicare (OM) in six states [Medicare Rights Center].

The WISeR Model: An AI Experiment

The CMS launched a six-year model, called the Wasteful and Inappropriate Service Reduction (WISeR) Model, in January of this year [Medicare Rights Center]. This initiative introduces an AI-forward prior authorization system for a limited number of OM services in New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington [Medicare Rights Center]. Historically, Original Medicare has utilized very little prior authorization compared to Medicare Advantage, presenting fewer barriers to accessing care [Medicare Rights Center].

The procedures covered by WISeR are varied, encompassing certain pain injections, spinal surgeries, and nerve treatments [Medicare Rights Center]. The stated goal of the WISeR model is to focus on health outcomes and measure quality, moving away from process and paperwork as success metrics [CMS Newsroom]. However, new records and previous reports indicate that this AI model is leading to inappropriate delays, denials of care, increased burden on providers, and harm for people relying on OM [Medicare Rights Center].

Concerns Over Delays and Denials

Implementation of WISeR has reportedly increased the time beneficiaries have had to wait for their procedures [Medicare Rights Center]. This is often due to the necessity of navigating denial and appeals processes, adding stress and prolonging access to needed medical care [Medicare Rights Center].

Reports suggest that the WISeR model may have a built-in bias towards denying care. The AI companies involved in making the initial coverage decisions reportedly receive more payment if they block access to medical services [Medicare Rights Center]. While human clinicians are meant to review the AI's decisions, studies indicate that these clinicians are likely to be influenced by the initial denials presented by the AI [Medicare Rights Center]. This raises concerns about the objectivity and fairness of the system.

Potential Expansion and Your Role

Despite the emerging concerns, there have been reports that CMS intends to expand the WISeR model to cover additional types of treatments, including those for oncology or cardiac care [Medicare Rights Center]. This potential expansion highlights the importance for beneficiaries, their families, and advocates to understand how these systems work and to be prepared to address issues should they arise.

While inappropriate denials cannot always be fully remedied through appeals, it is important to remember that you have the right to appeal any denial of care or services. If you or a loved one encounter a denial or delay of care due to prior authorization under Medicare, particularly in the states where WISeR is active, it is crucial to understand your appeal rights and seek assistance from trusted resources. Staying informed about changes to Medicare policies helps ensure you can access the care you need when you need it.