AI Pilot Program For Medicare

Observant1

Key Points

• The Trump administration initiated a pilot program on Jan. 1, requiring prior authorization
for some procedures in traditional Medicare in six states.

• The Wiser Model, which involves AI firms, targets procedures that accounted for 5.3%
of all Part B spending in traditional Medicare in 2024.

• The introduction of AI-driven prior authorization in traditional Medicare blurs the lines
with Medicare Advantage plans, raising concerns about coverage decisions.

https://www.msn.com/en-us/money/insurance/ai-is-coming-for-medicare-how-to-protect-yourself/ar-AA1W9soX

WABAC

I'm not sure what to make of this. Medicare has always had things that it didn't cover, at all.

I am most familiar with high-flow oxygen to treat cluster headaches. Medicare only ever "covered" oxygen for clusters during medical trials that have now ended. It subsequently (2021) left the coverage determination up to the regional MAC's. My MAC--Noridian--does allow it, for now.

My guess is that they're looking at factors like over-prescribing, or too new to properly assess best uses. There may be other factors as well. I know my sister-in-law dearly wishes she had got Medicare to buy her a CPAP machine for her apnea rather than a surgical neural stimulating implant.

Needless to say that Medicare doesn't pay for the FDA approved (2017) external vagus nerve stimulator to treat cluster headache.

Old_Joe

Well, it's no secret that there are always a few bad actors out there who figure out a way to bull Medicare or Medicaid for exorbitant fees for doing not much of anything. I'd think that AI could be a powerful tool in detecting those guys.