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The House Appropriations Committee voted to cut funding to the Centers for Medicare and Medicaid Services’ (CMS’) controversial, AI-powered prior authorization model known as the Wasteful and Inappropriate Service Reduction (WISeR) Model, following months of complaints and controversies about how the pilot hindered patient care across six states. The provision would also prohibit any form of prior authorization in traditional Medicare. It remains to be seen if the provision survives the sure to be bumpy appropriations process and becomes law.

WISeR, currently in a pilot testing phase in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington, introduced prior authorization into traditional Medicare for selected procedures, including certain pain management procedures performed by IRs. The rollout of the model has been plagued by technical failures, inconsistent application of criteria and other hurdles that have harmed patients’ access to care.

SIR has been working with allied medical specialty societies to inform Congress and CMS of the extreme challenges posed by prior authorization. SIR joined the Alliance of Specialty Medicine in a letter to CMS urging that agency to take stronger regulatory action against the use of prior authorization and the delays in patient care it causes. The letter also calls on CMS to implement an enforcement mechanism “such as a penalty for non-compliance or requiring that payers automatically provide approval for a request should they fail to meet the decision timeframe.” The letter is in response to proposed CMS regulations to improve the electronic exchange of healthcare data and streamline prior authorization processes through enhanced interoperability.