The Trump administration plans to start a pilot program to target wasteful Medicare spending. Texas, along with Arizona, New Jersey, Ohio, Oklahoma and Washington will be part of this pilot program.
According to a study published in the Journal of the American Medical Association, waste represents up to 25% of health care spending in the United States, and Medicare spent up to $5.8 billion in 2022 on unnecessary or inappropriate services with little to no clinical benefit.
Through the Wasteful and Inappropriate Service Reduction (WISeR) Model, the Centers for Medicare & Medicaid Services (CMS) will partner with companies specializing in enhanced technologies to test ways to provide an improved and expedited prior authorization process.
“The federal government plans to hire private companies to use artificial intelligence to determine whether patients would be covered for some procedures,” Reed Abelson and Teddy Rosenbluth wrote in the New York Times.
“CMS is committed to crushing fraud, waste, and abuse, and the WISeR Model will help root out waste in Original Medicare,” said CMS Administrator Dr. Mehmet Oz. “Combining the speed of technology and the experienced clinicians, this new model helps bring Medicare into the 21st century by testing a streamlined prior authorization process, while protecting Medicare beneficiaries from being given unnecessary and often costly procedures.”
“Low-value services, such as those of focus in WISeR, offer patients minimal benefit and, in some cases, can result in physical harm and psychological stress,” said Abe Sutton, Director of the CMS Innovation Center. “They also increase patient costs, while inflating health care spending.”
The AI will focus on skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy. The model excludes inpatient-only services, emergency services, and services that would pose a substantial risk to patients if significantly delayed.
While technology will support the review process, final decisions will be made by licensed clinicians.
