AI Companies Stand to Gain From Medicare Savings as Patients Fear Care Cuts
Summary
A federal Medicare pilot expanded prior authorization requirements for certain procedures in six states and assigned private technology contractors to review requests. CMS later cited several contractors for delays, missing notices, an inactive portal and questioned denial patterns, while contractors described problems tied to a rushed launch.Key Facts
- The WISeR pilot applies in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington.
- The pilot requires advance approval for more than a dozen procedures that generally did not previously require it under traditional Medicare.
- CMS invited contractors to use artificial intelligence and machine learning to review requests.
- The Government Accountability Office found that contractor pay is calculated based on requests that did not result in a paid claim.
- CMS rules require a human clinician to review every denial, and contractors lose payment for a case if a patient wins an appeal.
- CMS told Genzeon in February that 459 cases were awaiting decision letters, including some that had been pending for 23 days, despite a three-day decision deadline.
- CMS said Zyter had not sent prior-authorization decision letters and questioned whether it had adequate processes for provider complaints.
- CMS cited Virtix over incomplete letters and questioned denial patterns; it also demanded corrective action from Innovaccer after the company's online portal missed its deadline.
Read the Full Article
This is a fact-based summary from The Actual News. Click below to read the complete story directly from the original source.
