The Centers for Medicare & Medicaid Services set out to align incentives. It has succeeded. They are aligned, with great precision, against the word "yes."
The Pilot
Since January, a Medicare experiment called WISeR has put AI-assisted prior authorization into Original Medicare in six states. The name stands for Wasteful and Inappropriate Service Reduction, an acronym that did not so much get chosen as confess. Procedures such as epidural steroid injections, cervical fusion, and nerve stimulators now have to clear a private contractor before a senior gets them.
Records pried loose by the Electronic Frontier Foundation through a lawsuit show two vendors denied 5,944 requests in the first three months. In Washington, the contractor, Virtix Health, denied more than it approved: a 53% denial rate, according to The Seattle Times. Arizona, running the same pilot, stayed under 20%.
Medicine, it turns out, varies by zip code. Or something does.
The Incentive
Contractors are paid out of the spending they avoid. Sen. Patty Murray put it this way: "This is run by a for-profit contractor, and they are paid a percentage of the care they deny. That's outrageous." She is not alone in noticing. CMS's own actuarial staff reportedly wrote that participants "will have an incentive to deny as many claims as possible."
Even now, the penalty for being slow or wrong is a pay cut of 5 to 10 percent, per the EFF. One presumes it was calibrated to be felt mostly in spirit.
The government has built a vending machine that pays out only when it says no. The Algorithm was unavailable for comment.
The Paperwork
A month before launch, the vendor Innovaccer reportedly told CMS it would deploy software without full functionality, citing "changing requirements," "unclear governance," and too little testing time. Its summary: "auto-affirming is the only path available." CMS did not delay the launch.
The official standard is a decision within 72 hours. The EFF's records show one request sitting unanswered for 83 days, which is roughly 27 and a half deadlines. Nobody can say the system wasn't thorough.
The Response
CMS says WISeR "helps protect American taxpayers by leveraging enhanced technologies to ensure timely and appropriate Medicare payment." "Timely" is doing a great deal of lifting in that sentence, with the candor of a smoke detector that has been told it is merely a decorative feature.
And yet, as if this were not enough, an internal CMS planning document lists possible future services for the program: air ambulance transport, cancer treatment, and MRI scans. These are, one notes, services where the decision tends to be time-sensitive. Murray's response: "This cannot continue, and it absolutely cannot expand."
The experts have filed the report. The inbox, as ever, is full.
Sources: EFF — New Records Reveal Problems with Medicare's AI Prior Authorization Experiment · KUOW — The feds are using AI to deny care to WA seniors, Sen. Murray says · The Seattle Times via Rep. DelBene — Medicare AI program hit WA with 'staggering' denial rate
