A group of 17 Democrats from the House of Representatives have questioned the Centers for Medicare & Medicaid Services’ (CMS) decision to test the use of prior authorization in Medicare given the negative experiences that many Medicare Advantage members and their providers have had with the process.
In a letter to CMS Administrator Dr. Mehmet Oz, the lawmakers said that the model will likely limit Medicare enrollees’ access to care, increase the burden on an overburdened health care workforce, and create perverse incentives to put profit over patients.
RELATED: New CMS model will test prior authorization in Original Medicare
In late June, CMS announced that it will launch a voluntary Medicare model on January 1, 2026, in six states to test whether enhanced technologies like artificial intelligence (AI) can speed up the prior authorization process. The Wasteful and Inappropriate Service Reduction (WISeR) Model for Original Medicare calls for companies that specialize in AI and machine learning to partner with CMS to test ways to improve and streamline prior authorization within Original Medicare’s existing processes. The agency will pilot the program in New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington and focus on what it describes as low-value services, such as skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy for knee osteoarthritis.
But a group of 17 lawmakers, led by U.S. Representatives Suzan DelBene (D-Wash.) and Ami Bera (D-Calif.), say that the model will add new red tape to traditional Medicare that will delay care and worsen health outcomes. While prior authorization is often described as a cost-containment strategy, in practice it has been found to increase provider burden, take time away from patients, limit patients’ access to life-saving care, and create unnecessary administrative burden, they wrote in the August 7 letter.
Indeed, prior authorization has become a hot-button issue in Medicare Advantage. Its use has spiked as more seniors enroll in the plans. In 2023, Medicare Advantage made roughly 50 million prior authorization determinations, according to a KFF report. And a 2018 report by the Office of Inspector General found that 75 percent of denied prior authorization requests were overturned upon appeal, which DelBene said suggested that inappropriate initial denials were widespread. Furthermore, a 2022 OIG report found that some Medicare Advantage plans frequently violated Medicare coverage rules in their use of prior authorization.
So many patients and providers have complained about prior authorization requirements that in June, 50 health insurers signed a commitment to streamline, simplify, and reduce prior authorization. Dr. Oz and Robert F. Kennedy Jr., secretary of the Department of Health and Human Services, hailed the decision. Yet, the lawmakers said, less than a week later, HHS and CMS announced plans to test prior authorization in Medicare.
RELATED: Dozens of health plans join forces to simplify prior authorization
Lawmakers told Dr. Oz in the letter that they were particularly troubled that the WISeR model will contract with Medicare Advantage plans that have abused prior authorization to run these demonstrations.
"Prior authorization has long been abused, and it is bad for patients and providers,” they wrote. “We urge you to put patients and providers first by cancelling the WISeR model and exploring other ways to limit fraud, waste, and abuse in the Medicare program.”
Meanwhile, they asked for additional information about the model by Sept. 1, including:
- Criteria used to select the six states
- Services that will be subject to prior authorization in each state
- Required qualifications for entities performing prior authorization
| - Education plans for patients and providers about the new requirements and appeal rights
- Plans to review contracted entities’ algorithms to ensure inappropriate denials of medically necessary care
- Performance metrics for entities performing prior authorization
- The type of protections or thresholds that CMS will have in place to ensure that denials are evidence-based, not volume-driven