On December 26, MedPage Today released an article titled, “Medicare Is of Two Minds on Prior Authorization” that describes CMS expanding its use of prior authorization in traditional Medicare while simultaneously cracking down on its use in Medicare Advantage. The article quoted Marsha Simon’s comments on IT vendors that contract with CMS to implement the WISeR model.
“This is not actually the first time that prior authorization has been used in traditional Medicare, according to Marsha Simon, PhD, adjunct professor of health policy at George Washington University in Washington. Prior authorization has worked well there when it comes to the purchase of electric scooters and the use of ambulances to transport patients to routine dialysis appointments; both of those items had been involved in allegations of fraud or overuse, she said.
“It’s not prior authorization that’s the problem; it’s the vendors who are conflicted,” said Simon. She was referring to the information technology (IT) vendors that CMS has contracted with to implement the WISeR Model. Under the model, the vendors are paid a share of the savings generated by the claims that they deny.”