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Pre-approval of some procedures being piloted by Medicare - Motley Fool
A significant advantage of so-called “original Medicare” is that pre-approval for most medical procedures is not normally required, as is often the case for many medical procedures under private Medicare Advantage (MA) plans. Indeed, this is frequently the very reason many seniors opt to stick with “original Medicare” rather than enroll in a Medicare Advantage plan which usually offers additional fringe benefits.
As explained in this Motley Fool article by Christy Bieber, that may soon be a thing of the past, as CMS (the Centers for Medicare & Medicaid Services) is now piloting a program called “WISeR” (Wasteful and Inappropriate Service Reduction) - an AI-based method to ferret out wasteful Medicare spending. The pilot is being conducted in seven U.S. states (Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington) introducing prior authorization for some potentially wasteful medical procedures, including these:
Skin and tissue substitutes and related wound care.
Electrical nerve stimulator implants.
Knee arthroscopy for knee osteoarthritis.
Epidural steroid injections for pain management.
Hypoglossal nerve stimulation for obstructive sleep apnea.
Understandably, senior advocates are concerned that this could lead to denial of necessary services, although the pilot program is now restricted to just a few states, and benefits deemed truly necessary will still be covered under Medicare. All of this is explained in this Motley Fool article by Christy Bieber.
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