APMA Continues Advocacy Against Expanded Use of Prior Authorization in Medicare

APMA continues its strong advocacy against the Centers for Medicare & Medicaid Services' (CMS) Wasteful and Inappropriate Service Reduction (WISeR) Model. APMA recently endorsed the Seniors Deserve SMARTER (Streamlined Medical Approvals for Timely, Efficient Recovery) Care Act. The legislation, introduced by Senator Patty Murray (D-WA) and Senator Ron Wyden (D-OR), would prohibit implementation of the WISeR Model and prevent the expanded use of prior authorization in fee-for-service Medicare. APMA previously endorsed the bill's House counterpart (HR 5940) introduced by Representative Suzan DelBene (D-WA).

As the debate over WISeR continues, CMS has offered additional details about how the model would operate in practice. During a recent webinar, CMS explained that the model would apply across four sites of service: hospital outpatient departments, ambulatory surgical centers (ASC), physician offices, and home settings. CMS also highlighted key differences between facility and professional claims. In hospital outpatient and ASC settings, prior authorization and prepayment review will be implemented for the facility claim first, with professional claims subsequently flagged through an associated code list. In office and home settings, professional encounters and claims will be subject to prior authorization and prepayment review.

Additional background and details are available at APMA's WISeR Model Resource page.