The Centers for Medicare & Medicaid Services (CMS) is announcing a very new innovation center model that is aimed at enabling to ensure that people with original Medicare to ensure they receive safe, necessary, and efficient care. By way of Wasteful and Inappropriate Service Reduction – WISeR model, CMS is going to collaborate with companies that specialize in enhanced technologies so as to test ways in order to provide enhanced as well as fast prior authorized processes, which are relative to the existing processes from original Medicare, and help patients and also the providers to avoid certain unnecessary or inappropriate care, thereby safeguarding federal taxpayers dollars. This kind of model happens to build on other changes that are being made to prior authorization, as has been announced by the US Department of Health and Human Services as well as CMS.
According to Dr. Mehmet Oz, who happens to be the CMS administrator, CMS is indeed committed to crushing any sort of fraud, waste, and abuse, and this WISeR model will help to root out waste within the original Medicare. Blending the speed of technology along with the experiences, this new model will enable to bring Medicare into the 21st century by testing and authorizing a process that is streamlined while at the same time also safeguarding the Medicare beneficiaries from getting unnecessary and often expensive procedures.
Wasteful care, which includes services that offer little to no clinical advantage, not just increases the cost, but at the same time, it also puts the patient’s life at risk. Waste in healthcare happens to represent almost 25% of healthcare spending in the United States. The Medicare Payment Advisory Commission goes on to estimate that around $6 billion in Medicare spending in 2022 alone happened to be spent on services that gave minimal benefit. According to Abe Sutton, the CMS Innovation Center director, low-value services like those that focus on WISeR go on to offer patients low benefits and, in some cases, can result in even physical harm as well as psychological stress. They also grow the cost of patients while, at the same time, inflating healthcare expenditure.
Apparently, the WISeR model is going to test a new process to see if enhanced technologies, which include artificial intelligence, can speed up the prior authorization processes for certain items and services that have been identified as especially susceptible to waste, fraud, and abuse, or even, for that matter, appropriate usage. These items as well as services include, however, are not limited to skin and tissue substitutes, knee arthroscopy for knee osteoarthritis, and electrical nerve stimulator implants. The model happens to exclude any inpatient-only services, emergency services, or even services that kind of pose a substantial risk to patients if they somehow get significantly delayed.
It is well to be noted that the companies that are selected to participate in the model are going to operate within the assigned geographic locations and have to have clinicians who possess actual expertise in order to conduct medical reviews as well as validate coverage determinations. Moreover, while the technology will support the review process, final decisions, which include a request for one of the selected services if it does not meet the requirements in Medicare coverage, are going to be made by licensed clinicians and not the machines.
Interestingly, model participants are going to receive payments based on their capacity to decrease the unnecessary or non-covered services and even lower the spending within the original Medicare. The payments of the participants will be adjusted based on their performance as per the established quality as well as process measures that take care of the model participants capacity in order to support decision-making, which is faster for providers as well as supplies, and also enhance the supplier, provider, and beneficiary experience with a process that is prior authorized.
The WISeRÂ model is not going to change the Medicare coverage or even the payment criteria. Healthcare coverage coming from the original Medicare beneficiaries is going to remain the same, and the beneficiaries will retain the freedom in order to look out for care from their preferred provider or supplier.
Under this model, the providers and the supplies in the assigned regions are going to have the choice of submitting the prior authorization request for certain items as well as services, or else their claim will be subject to a prepayment medical review.
The providers and suppliers that choose to submit a prior authorization may as well either go to submit their request directly to the model participants or to the Medicare administrative contractor, who will forward the request to the model participant. CMS may as well include a path in the future that will enable the providers as well as suppliers with a robust compliance record in order to qualify for exemptions within the WISeR review, which would in a way further decrease the administrative burden and enable a much greater focus when it comes to high-risk areas. It is well to be noted that the WISeR model does not affect people who are already enrolled in the Medicare Advantage. Apparently, CMS has already gone on to issue a Request for Applications for companies interested in being a part of the WISeR model.
