Will the WISeR Model Lead to Improved Quality of Care?

Last month, Healthcare Innovation reported on the WISeR (Wasteful and Inappropriate Service Reduction) model, a new model being tested by the Centers for Medicare & Medicaid Services (CMS) Innovation Center that applies prior authorization processes to Traditional Medicare. The model will use artificial intelligence (AI) to review items and services that CMS deems vulnerable to fraud, waste, and abuse.

As Congress scrutinizes prior authorization practices in Medicare Advantage (MA) and CMS begins using the WISeR model, Norton Rose Fulbright’s Jeff Wurzburg expressed seeing the once-clear lines between the two programs starting to blur, which he believes could carry meaningful consequences for both providers and patients.

Healthcare Innovation recently spoke with Jeff Wurzburg, a former attorney in the Health and Human Services (HHS) Office of General Counsel, who now advises providers and health systems on navigating today’s complex regulatory terrain. Wurzburg believes stakeholders should be preparing for potential federal action and industry-wide shifts in how prior authorization is managed and enforced.

Could you talk about the changes in prior authorization that you’re seeing?

The first thing I'll just note is the interest in prior authorization, and in particular, the fact that members of Congress are interested. We have some draft legislation and increasing oversight that we've seen from the government, both on Capitol Hill, but more acutely at the Centers for Medicare and Medicaid. While we haven't seen true reforms yet, I do believe that's where we're heading. This reminds me of what happened with surprise billing a little more than a decade ago, when it started to get more attention. You saw more coverage in the media, and you would read stories about instances where individuals received unexpected, large bills, where they had gone to an in-network hospital, but you had a drive-by physician that came by, and so they got this out-of-network bill. With the No Surprises Act, Congress moved on this. It's worth noting that CMS actually had proposed some changes over the years, but deferred to the states on some of the more stringent network adequacy requirements that were proposed. And over time, nothing happened, and then Congress stepped in.

I believe that if there isn't movement in terms of reforms to prior authorization, in particular in the Medicare space, I do think that Congress will eventually step in, because they are hearing about it from their constituents, and ultimately that drives their interest and their time and where they legislate.

Could you tell me more about the WISeR model?

It's focused on traditional Medicare. Previously, one of the distinctions of traditional Medicare versus MA was that MA beneficiaries would have to deal with utilization management. This would now apply prior authorization more to traditional Medicare. I think that's extremely noteworthy. I think it's noteworthy that it's considered to be a voluntary model, which it will be for the technology companies that choose to participate, but it will not be for the providers and the Medicare beneficiaries that are subject to prior authorization requirements. From that perspective, the Center for Medicare and Medicaid Innovation (CMMI) is kind of a perfect testing ground for that.

There are many interesting things about this proposed model. Still, one of the interesting things, I thought, is that CMS did confirm that final decisions are going to be made by clinicians, and that aligns with some guidance from February 2024, and the FAQ that they put out. The FAQ talked about the use of algorithms or software in making prior authorization determinations. And they had said, you can use algorithm software, but each claim needs to be individually reviewed, as is required under the Medicare statute. The current administration hasn't addressed that specifically, but this would seem to align with that as well.

The other thing about the WISeR model is… it's really important to look at the purpose of the CMMI, and it's part of the Affordable Care Act (ACA). It's interesting to see this administration, once again, relying on provisions of the ACA to advance their policy priorities. And the purpose of CMMI, according to statute, is to test innovative payment and service delivery models to reduce program expenditures while improving quality of care. With the WISeR model, will it improve quality of care? One of the things that CMS said in the request for applications is that there's a lot of fraudulent care, there's a lot of unnecessary care, and so that's the basis for this.

CMMI historically has sought to expand coverage and look to increase benefits or create efficiencies for beneficiaries, which ultimately streamlines care. And here you have a situation where this could be an impediment to care, and that's something new and very noteworthy.

It's kind of a contradiction to the announcement about their work with insurers, which stated they would streamline and reduce prior authorization use. At the same time, you have CMS coming in with new prior authorization requirements for traditional Medicare and almost aligning it with MA. CMS says, well, we looked at what MA plans are doing with regard to prior authorization, and we base our approach on what they're doing. There is some mixed messaging from CMS regarding reforming prior authorization when you're now implementing it in traditional Medicare like this.

What do you anticipate will happen with these new developments?

I'm curious to see who the applicants will be, in terms of the technology companies that want to step in. I anticipate frustrated providers and beneficiaries who are not used to prior authorization in such a fashion under traditional Medicare. It certainly creates additional burden for providers, and I believe prior authorization in traditional Medicare will ultimately lead to confused and frustrated Medicare beneficiaries, which may ultimately lead to more attention being paid to prior authorization in a manner that will then drive reform.

Could you explain a little bit more what you see with Medicare and MA, as in, how this will change?

It's too early to tell how MA prior authorization will change. Certainly, you have the pledge by insurers, but it's still just a pledge. These were relatively vague announcements, so the proof will be in the pudding as to whether or not reforms are implemented in the MA space, I should say voluntary reforms in the MA space, with regard to traditional Medicare. The question becomes whether the results of the CMMI model, the WISeR model, will be replicated. And ultimately, that's what the statute intends: you are testing these innovative models to see if they really do improve call quality, reduce cost, and if so, then have them be applied across the program. Or does this ultimately lead to frustration from providers and beneficiaries, and the model is either terminated early or not renewed or expanded upon its conclusion.

What other concerns are you seeing with these new developments?

One concern is the burden on providers and beneficiaries. This will be an additional step for beneficiaries to receive services that have already been approved for coverage. CMS has already made determinations that these services are appropriate for coverage. Now, perhaps this model will lead to determinations that some of these procedures should no longer be covered, but that seems unlikely given their historical coverage and previous examination for appropriateness in this population.

Do you expect these guidelines to be a lasting change?

I would be surprised if additional prior authorization is popular and does not lead to additional scrutiny of its utilization for Medicare beneficiaries.

What do you see as a potential upside?

The protection of the beneficiary is always the top priority of CMS. If ultimately this model shows that there was unnecessary care being provided to beneficiaries, then that would be a positive thing.

What are your thoughts on making prior authorization better?

Utilization management is, and will always be, a part of managed care. Management is in the name; the idea is more efficient, controlled care that provides better quality services and improved care for beneficiaries. But we've seen that in MA, prior authorization can be an impediment to care for beneficiaries, and ultimately, if that is where the WISeR program leads, it's likely to create further scrutiny and reforms with regard to utilization management processes within the Medicare MA programs.

What do you foresee happening in the near future and further ahead?

In the near future, I anticipate increasing scrutiny on prior authorization practices across the industry, whether it's MA products, Medicaid, managed care, or commercial insurance. There have been questions raised about the utilization of this as a practice, and I don't anticipate that to change. In fact, just a couple of months ago, I believe bipartisan legislation was introduced in Congress. To me, this is the beginning of the discussion about prior authorization, and we're still quite a bit away from any final determinations or changes in policy.

The main takeaway is that attention to prior authorization practices is here to stay. And a CMMI model that potentially impedes coverage is a sea change in terms of priorities of the innovation center.