CMS Announces Prior Authorization Test Model

The Centers for Medicare and Medicaid Services (CMS) revealed a new plan to address waste, fraud and abuse in traditional Medicare with the introduction of its Wasteful and Inappropriate Services Reduction (WISeR) Model June 27. The WISeR test model will introduce prior authorization using artificial intelligence (AI) technology for a select number of services, including some interventional radiology procedures. It is a six-year program that will begin Jan. 1, in six states.

“Congress passed the PAMA Act in 2014 to address concerns regarding imaging utilization. Instead of implementing that bipartisan legislation, CMS is now for the first time starting a prior-authorization program that questions many services ordered by providers -- including some interventional radiology procedures,” said Alan Matsumoto, MD, FACR, chair of the ACR® Board of Chancellors. “If CMS had implemented the PAMA AUC-based imaging exam and procedure ordering program at any point in the last 11 years, this demonstration project may not have been necessary. We urge CMS to ensure this program is fair, transparent, and causes as little disruption as possible.”

WISeR will be based on CMS Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs) in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington. CMS selected a group of 11 services and procedures to include in the model in the first year and potentially expand to include other services in later years. The initial list of services includes percutaneous vertebral augmentation for vertebral compression fractures, epidural steroid injections for pain management, and percutaneous image-guided lumbar decompressions for lumbar spinal stenosis.

In the model, providers may choose to utilize AI tools to obtain prior authorization before performing a procedure. If the provider chooses not to follow the process in advance, the claim will be flagged by the Medicare Administrative Contractor (MAC) for prepayment review, and providers will be required to respond to requests for pertinent information if necessary.

CMS is accepting applications for technology partners to implement and streamline the program. The selected participants will be paid a percentage of demonstrated reductions in spending for services deemed medically unnecessary or non-covered in accordance with coverage guidelines outlined in the LCDs or NCDs.

For additional information about the WISeR model, contact Katie Keysor, ACR Senior Director, Economic Policy.