WSMA Supports Legislation to Repeal Medicare Prior Authorization Pilot Program

The WSMA is supporting a bill introduced in the U.S. House of Representatives last week that seeks to block the new Medicare prior authorization pilot program due to begin in January in select states. Sponsored by Suzan DelBene (WA-0) and co-signed by Kim Schrier, MD (WA-08) and Rick Larsen (WA-02) among others, the Seniors Deserve SMARTER (Streamlined Medical Approvals for Timely, Efficient Recovery) Care Act would repeal the Wasteful and Inappropriate Service Reduction model, the utilization management demonstration being piloted by the Centers for Medicare and Medicaid Services in Washington as well as Arizona, New Jersey, Ohio, Oklahoma, and Texas.

In addition to advocating for the bill’s passage, the WSMA continues to raise concerns about the pilot program, which will apply prior authorization requirements to selected services with third-party artificial intelligence vendors playing a significant role in determinations. As we reported in last week’s Advocacy Report, the WSMA led a coalition of state medical associations from the six impacted states to send a letter to CMS Administrator Dr. Mehmet Oz expressing serious concerns about the model. In our letter, we stress the following points:

• While the program aims to improve accountability and reduce waste in Medicare, its current design could delay care, reduce access, and increase administrative burdens on physicians and patients alike.
• The WISeR Model expands the burdensome prior authorization processes that physicians already experience in Medicare Advantage and the commercial insurance markets into traditional Medicare.
• The vendor incentive structure within the WISeR Model could result in excessive denials motivated more by the potential for vendor profit than by fair and balanced clinical judgment. (Note: CMS announced last week that Virtix Health would serve as the AI vendor for Washington state.)

About half of Washington state’s 1.6 million Medicare beneficiaries are enrolled in traditional Medicare. With this controversial program, those Washingtonians will soon be at risk of experiencing the same care delays and denials familiar to physicians and that increasingly characterize prior authorization in the media. With patient care a top priority, the WSMA is continuing to share our concerns with the public, with recent stories published in the Washington State Standard and Modern Healthcare.

The WSMA will keep members apprised of developments as the implementation date grows closer.