Ohio is one of six states selected for this pilot, which targets what the Centers for Medicare and Medicaid Services (CMS) identifies as services vulnerable to waste, fraud, and abuse. Approximately 1.1 million people in Ohio rely on traditional Medicare.
Key Details of the WISeR Program:
Procedures Covered: Approximately 17 specific outpatient procedures, including certain pain management epidurals and treatments for Parkinson’s disease, will require prior authorization. Emergency and inpatient services are not included.
How it Works: Doctors treating Medicare patients for these procedures must first request approval from a technology company contracted by the government. The program is technically voluntary, but providers risk non-reimbursement if they do not receive a pre-approval.
AI’s Role: While AI will screen and assist in the review process, a licensed clinician will make the final decision on any denial. The contracted companies will be financially incentivized by a percentage of savings but can also be penalized for “inappropriate denials.”
Purpose: The CMS states the program is designed to prevent Medicare from paying for procedures that offer little to no clinical benefit.
Concerns and Perspectives
The new program has drawn mixed reactions from healthcare professionals and patient advocates.
Concerns about delays and burden: Organizations like the Ohio State Medical Association have voiced strong concerns. CEO Todd Baker stated, “It creates significant administrative burden. It potentially creates risks of care delay,” adding that they worry this could make prior authorization more common in traditional Medicare. The Ohio Hospital Association echoed these concerns, stating they want to ensure the requirements do not “create inappropriate barriers to patient care or administrative burden.”
Minimal impact predicted: Other experts, such as Brian C. Moore from Ohio Medicare Plan, believe the program’s limited scope will affect only a small percentage of beneficiaries. He stated, “The only people that should be concerned…are people that may be subject to one of these 17 types of outpatient services.”
Patients can appeal a denial, but advocacy groups like UHCAN Ohio worry the process will be stressful and confusing for many Medicare recipients, especially older adults with chronic pain conditions.
The CMS maintains that the program is meant to improve oversight and ensure the longevity of the Medicare system.