Things very slippery at CMS

I had just finished a guest column for the Westchester Examiner on how Dr. Oz is scamming us into believing he and RFK Jr. are doing great things for us by making Medicare so easy. 

Oz is a showman. Several weeks ago he put out a video encouraging people to get help from the experts at Medicare. But he doesn’t point us at traditional Medicare – there’s no profit in that. He directs us squarely to the industry’s privatized version, Medicare Advantage. 

He’s also a salesman. Later in the month he put out a video about how CMS and their corporate collaborators are now pledging to clean up Medicare Advantage’s scandalous abuse of prior authorizations to delay or deny care. Mind you, they’re just pledging for the moment. No new laws or punishments as yet.

As I wrote in the Examiner, I believe fixing prior authorizations in Medicare Advantage is part of a larger campaign, to turn a proposal in Project 2025 into a reality, that Medicare Advantage (Part C) rather than traditional Medicare (Parts A and B) will become the default for new enrollees. 

Having no trust in Oz or his boss RFK Jr. already, I was not totally surprised reading yesterday’s CMS press release that said they’re going after prior authorizations in Original Medicare as well.

But, the thing about prior authorizations in O.M. is that there isn’t much use of it there at all. If doctors want you to have something done, there’s no middleman private insurance company gatekeeper barring your access to that procedure. Medicare will pick up its share of the cost, and you or your supplemental policy will pick up the rest. No unexpected delays or denials.

Today’s post in HEALTH CARE un-covered explains how the limited use of prior authorizations works in O.M.:

Not many people realize that prior authorization is used in traditional Medicare (TM) at all, likely because it applies to a very small small number of services. Currently, TM requires prior authorization for 52 outpatient medical services, some durable medical equipment, and repetitive scheduled non-emergent ambulance transport. The prior authorizations are processed by the Medicare Administrative Contractors (MACs) and are required to be reviewed in a very short timeframe. Perhaps most importantly, the prior authorization decisions under the current process have been found to be more than 98% accurate. The limited scope, MAC review, and high accuracy ensure that current policies and procedures governing the use of prior authorization in traditional Medicare meet the intended goal of preventing wasteful spending without delaying or denying necessary care.

In the guise of going after “fraud, waste, and abuse,” the Oz’s newsletter says the agency is now planning to test something in traditional Medicare called the WISeR (Wasteful and Inappropriate Service Reduction) Model. Here’s how it’s described:

Combining the speed of technology and the experienced clinicians, this new model helps bring Medicare into the 21st century by testing a streamlined prior authorization process, while protecting Medicare beneficiaries from being given unnecessary and often costly procedures . . .

The WISeR Model will test a new process on whether enhanced technologies, including artificial intelligence (AI), can expedite the prior authorization processes for selected items and services that have been identified as particularly vulnerable to fraud, waste, and abuse, or inappropriate use. . .

Under the model, providers and suppliers in the assigned regions will have the choice of submitting prior authorization requests for selected items and services or their claim will be subject to pre-payment medical review.

In the 6 years they’re planning to run this model, there’ll be plenty of time to open up new pathways to abuse in our health care system. We’ll soon be seeing poorly regulated and widespread use of prior authorization in traditional Medicare as well.

And just like with Medicare Advantage, it’s not only that private companies who’ll be running these requests through their AI systems, the final decisions will be made by “licensed clinicians, not machines.” They don’t say doctors, and they specifically don’t say your doctor, the guy who asked for the procedure in the first place.

I don’t trust these people at all. 

And I don’t trust the link for an “overview” that CMS gives in the press release. You have to sign into read it, I’m not inclined to sign into anything from the government that should be open to the public.   

I did go to another link at the bottom of the release, which has more of the same gobbledygook we’re used to reading:  “working with companies experienced in using enhanced technologies to expedite and improve the review process,” “ensure people . . . receive the most appropriate care,” “best health outcomes,” “ease administrative burdens,” “empowers patients to partner” with their providers.  The whole thing was probably written by A.I.

Check out the more informative post in HEALTH CARE uncovered mentioned above. You’ll hate what you read, but consider it medicine. 

If only they’d stick to selling snake oil and not perpetrate the worst of their greedy, slimy instincts on us.