Medicare is coming with changes, as the U.S. government has confirmed that beneficiaries will now be required to obtain prior authorization. More than 17 specific medical services will be affected. For now, this measure will begin as a pilot program in six states, and the goal is to fight fraud and waste in the healthcare system. While it promises greater efficiency, it has also raised concern among users and healthcare professionals over possible delays in care.
This change is very important, as until now only Medicare Advantage typically required prior authorizations. The new system, called the WISeR Model (Waiver for Inefficiencies in Services and Resources), will implement technological tools like artificial intelligence to evaluate suspected cases of unnecessary or abusive treatments. It may sound a bit like the Matrix, but don’t worry, final decisions will still be made by authorized doctors. Here’s everything you need to know.
What exactly is changing in Medicare?
Until now, users of Original Medicare (the traditional version of the system) did not need prior authorizations to access most services. That flexibility will now partly disappear with the arrival of the WISeR model, which will be implemented first in Arizona, Texas, Oklahoma, Ohio, Washington, and New Jersey.
Why? Because the Centers for Medicare & Medicaid Services (CMS) have reported high rates of fraud, abuse, or medically unnecessary procedures (according to their own assessments, of course). So this system will allow for prior evaluations to determine whether specific treatments should be applied or can be avoided.
How will the new system work?
Everything will be done through technology, although, as we said earlier, the final decision will be made (obviously) by a licensed doctor, not by a machine.
It is important to note that emergency services, hospitalizations, and treatments that could endanger health if delayed will be excluded from this policy, and it will not affect the program’s basic coverage or current rates.
Services subject to prior authorization:
- Electrical nerve stimulators
- Sacral nerve stimulation for urinary incontinence
- Phrenic nerve stimulator
- Deep brain stimulation for Parkinson’s
- Vagus nerve stimulation
- Induced lesions of nerve tracts
- Epidural steroid injections for pain
- Percutaneous vertebral augmentation (PVA)
- Cervical fusion
- Arthroscopic lavage and arthroscopic debridement for osteoarthritic knee
- Hypoglossal nerve stimulation for sleep apnea
- Incontinence control devices
- Diagnosis and treatment of impotence
- Percutaneous lumbar decompression for spinal stenosis
- Bioengineered skin substitutes for chronic wounds
- Application of cellular and tissue products (CTP) on wounds and lower limbs
Trump vs. public spending
As you can see, this government seems a little obsessed with public spending, don’t you think so? (well, it’s normal but it is quite obsessive under our point of view). The creation of DOGE also put Medicare and Social Security services under the spotlight… More than 300 people were prosecuted for medical scams with Medicare!!
More bureaucracy but less access
Of course, not everyone is convinced by this. Some experts think and believe that these authorizations will slow down care and add an unnecessary layer of paperwork… Or worse!
And what about people over 65?
The intention might be good (saving public money), but in practice it could make it harder for many to access the treatments they need quickly.
Only in 2023, fewer than half a million prior authorizations were requested under traditional Medicare.
An experiment… or the new path for Medicare?
This new model will be a test. If it works, it could be expanded across the country. But if it turns into a bureaucratic mess, it might end up like so many other failed attempts to “modernize” the system. We’ll have to wait and see.