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
Comments
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.
That's different from my situation where Medicare ignores the evidence and simply denies coverage to begin with, or hands it off to the MACs.
I don't know that Noridian would make more money if it suddenly decided to ignore the evidence and the recommendations of The American Headache Society. But they certainly have the authority to act capriciously. And this situation predates Bobby Baby.
"But while experts agree that wasteful spending exists, they worry that the pilot program may pave the way for traditional Medicare to adopt some of the most unpopular practices of private insurers."
https://archive.li/fC2wh
“The more expensive it is, the more likely it is to be denied,” said Jennifer Oliva, a professor at the Maurer School of Law at Indiana University-Bloomington, whose work focuses on AI regulation and health coverage.
Oliva explained in a recent paper for the Indiana Law Journal that when a patient is expected to die within a few years, health insurers are “motivated to rely on the algorithm.” As time passes and the patient or their provider is forced to appeal a denial, the chance of the patient dying during that process increases. The longer an appeal, the less likely the health insurer is to pay the claim, Oliva said.
“The No. 1 thing to do is make it very, very difficult for people to get high-cost services,” she said.
https://kffhealthnews.org/news/article/ai-medicare-prior-authorization-trump-pilot-program-wiser/
AI savings will be shared with AI providers, so there is a conflict of interest. AI can be programmed to be too aggressive in denials. Then, deal with complaints and appeals.
Appeals will be reviewed by "clinicians" - they could be doctors, nurses, clinical assistants, trainees. That's a problem now - insurers expect the ordering doctors to be on line, but they can staff approval departments with nurses.
I'm going to guess that my sister in law is on traditional medicare.