Why did CMS develop WISeR?
The Wasteful and Inappropriate Service Reduction (WISeR) Model reflects the CMS Innovation Center’s commitment to protect federal taxpayers and the Department of Health and Human Services (HHS) and CMS pledge to protect people with Original Medicare by crushing fraud, waste and abuse. In addition to saving taxpayer dollars, the model aims to reduce inappropriate, unnecessary and invasive procedures (in line with existing Original Medicare prior authorization policy) that can significantly harm patients while also improving upon the existing prior authorization process to streamline efficiency and improve accuracy by leveraging enhanced technologies.
How does WISeR fit into the Innovation Center Strategy?
WISeR addresses all three pillars of the Innovation Center’s strategic direction to:
- Promote evidence-based prevention by introducing clinical review with enhanced technology to ensure patients are receiving the most appropriate and effective care, which can include focusing more on prevention and less on costly, potentially invasive and inappropriate care.
- Empower people to achieve their health goals by setting the stage for beneficiaries partnering with their clinicians on the most effective care plans and, where possible, providing them with more information about their care.
- Drive choice and competition for people by applying new tools in Original Medicare; and by incentivizing participating companies to help deliver fast, accurate, transparent prior authorization decisions and holding those companies accountable for their performance.
Moving forward, the Innovation Center will prioritize the role of technology in improving quality and reducing cost.
Will WISer change Original Medicare coverage or payment policy?
WISeR does not change Medicare coverage or payment policy. Health care coverage for people with Medicare will not change, and they retain the freedom to seek care from their Original Medicare provider or supplier of choice. Payment to providers and suppliers for covered services will not change under the model.
How will participating companies be held accountable?
While enhanced technology aims to expedite the prior authorization process, any recommendations that coverage should not be provisionally affirmed will be made by an appropriately licensed human clinician, not a machine. If the item or service is provided, providers, suppliers and people with Medicare will have the ability to appeal claims decisions as usual. Participating companies will be held to requirements such as:
- Demonstrated ability to interpret and apply clinical coverage criteria derived from National Coverage Determinations or Local Coverage Determinations
- Experience using enhanced technology, including with other payers or health plans, to streamline approval processes
- Timely responses to prior-authorization requests and resubmissions
- Ensuring appropriate clinical expertise is incorporated into the pre-approval process and to conduct medical reviews
- Compliance with all applicable federal and CMS data protection and security requirements
- Compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations and other applicable privacy and security laws and CMS policies
Capability to offer back-up options to advanced technologies, including phone, fax, electronic portals and regular mail
How will providers or suppliers in model test regions submit a prior authorization request?
Providers or suppliers in a designated region for the model who choose to submit a request for covered services will send all relevant information to support Medicare coverage of the selected services either directly to the company participating in WISeR for that region or to their Medicare Administrative Contractor (MAC), which will then route it to the model participant.
The model participant will use enhanced technology to support coverage determinations and seek medical review by clinicians with relevant expertise, as needed. Model participants will notify the provider or supplier of the decision.
Providers and suppliers, however, are not required to submit a prior authorization request for a selected service. Should they choose not to, the claim for that service would be subject to post-service/pre-payment medical review.
How can a provider, supplier or beneficiary appeal a decision?
For a “non-affirmed” prior authorization request — meaning that a future service was found not to meet Medicare coverage, coding or payment requirements — the provider/supplier has unlimited opportunities to resubmit a request. A non-affirmed decision does not prevent the provider/supplier from delivering the service and submitting a claim. Submission of such a claim and denial by the MAC will constitute an initial payment determination, which would be subject to the existing administrative appeals processes available to providers, suppliers and people with Medicare.
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