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CMS AI Prior Authorization Pilot Plagued by Delays and Technical Failures, Documents Reveal

CMS AI Prior Authorization Pilot Plagued by Delays and Technical Failures, Documents Reveal

Documents obtained through a Freedom of Information Act (FOIA) lawsuit by the Electronic Frontier Foundation (EFF) reveal widespread issues in the Centers for Medicare & Medicaid Services (CMS) Wasteful and Inappropriate Service Reduction (WISeR) Model, an AI-powered prior authorization program. The roughly 1,000 pages of records from the pilot's initial months outline significant problems including thousands of delayed approvals, miscommunications between tech vendors and Medicare Administrative Contractors (MACs), and provider frustration. Many prior authorization requests exceeded the program's three-day goal, with some remaining unanswered for over 80 days. Providers reported patients experiencing severe pain due to delayed procedures. Technical issues, system downtime, and a lack of communication from vendors, particularly Innovaccer in Ohio, were also cited. The WISeR model, launched on January 1, aims to curb improper spending in traditional Medicare by using AI for prior authorization in Arizona, O...

CMS AI Prior Authorization Pilot Faces Delays and Technical Failures, Documents Show

CMS AI Prior Authorization Pilot Faces Delays and Technical Failures, Documents Show

Documents obtained by the Electronic Frontier Foundation (EFF) through a Freedom of Information Act (FOIA) lawsuit reveal significant issues in the Centers for Medicare & Medicaid Services (CMS) Wasteful and Inappropriate Service Reduction (WISeR) Model, an AI prior authorization program. The roughly 1,000 pages of records from the program's initial months outline widespread problems including delayed approvals, miscommunication, and provider frustration. Thousands of prior authorization requests exceeded the pilot’s three-day turnaround goal, with some remaining unanswered for up to 83 days. The documents also detail miscommunications between tech vendors and Medicare Administrative Contractors (MACs), system downtime, and numerous complaints from providers about delays and lack of communication, particularly concerning the vendor Innovaccer.

Representatives Sewell and Castor Introduce Legislation to Extend Medicare Part D Premium Stabilization Program

Representatives Sewell and Castor Introduce Legislation to Extend Medicare Part D Premium Stabilization Program

U.S. Representatives Terri Sewell (D-Alabama) and Kathy Castor (D-Florida) have introduced the Affordable Premiums for Seniors Act. This legislation aims to extend the Medicare Part D Premium Stabilization Demonstration through 2029. The program, implemented by the Centers for Medicare & Medicaid Services (CMS) in 2025, was designed to limit premium increases for stand-alone Medicare prescription drug plans. It provided additional federal subsidies and capped annual premium hikes as insurers adjusted to changes under the Inflation Reduction Act, which shifted a greater share of prescription drug costs to Part D plans. The Trump administration announced in July that it would terminate this demonstration after 2026, citing that Part D insurers had gained sufficient experience with the redesigned benefit to support their pricing assumptions. Sewell's office, citing the Medicare Payment Advisory Commission, stated that the demonstration reduced beneficiaries' premiums by an average of $312 in 2026. The propose...

U.S. Congressman Chris Smith Calls for Reinstatement of Rule on Obamacare Abortion Coverage Transparency

U.S. Congressman Chris Smith Calls for Reinstatement of Rule on Obamacare Abortion Coverage Transparency

U.S. Congressman Chris Smith, who leads the congressional Pro-Life Caucus, is urging President Trump to reissue the Exchange Program Integrity Final Rule. This call follows a report from a nonpartisan federal watchdog, the Government Accountability Office (GAO), which found that nearly a third of Affordable Care Act (ACA) plans cover abortions. Specifically, 1,719 out of 6,655 qualified health plans offered on Obamacare exchanges cover “non-excepted abortion services,” meaning elective abortions not resulting from rape, incest, or danger to the mother’s life. The report indicates that approximately 4.4 million Americans are enrolled in Obamacare plans that include abortion coverage. Congressman Smith asserts that the ACA currently fails to apply the Hyde Amendment, which prohibits the use of federal funds for abortions except in specific circumstances, thereby allowing taxpayer dollars to subsidize these services. He also highlighted that some insurance issuers did not comply with the ACA’s consumer transp...

CMS Proposed Policy Changes Threaten Sustainability of Remote Patient Monitoring Programs

CMS Proposed Policy Changes Threaten Sustainability of Remote Patient Monitoring Programs

The Centers for Medicare and Medicaid Services (CMS) has proposed significant changes to the reimbursement policies for remote physiologic monitoring (RPM) and remote therapeutic monitoring (RTM) services. These proposed changes, embedded within a draft Medicare physician pay rule, would restrict payment for RPM and RTM services to only those furnished by clinical staff directly employed by the practice, effective January 1, 2027. This means that third-party vendors, which many providers currently rely on, would no longer be eligible for Medicare reimbursement. The move is driven by CMS's concerns regarding program integrity and the quality of care provided by some vendors. Payments for remote patient monitoring have seen a substantial increase, jumping 31% from $408 million in 2023 to $536 million in 2024, with nearly 1 million enrollees receiving these services in 2024. CMS is currently accepting public comments on the Physician Fee Schedule (PFS) rule, having received nearly 40,000 comments to date.

OIG Report Identifies Gaps in Medicare Advantage Durable Medical Equipment Fraud Prevention

OIG Report Identifies Gaps in Medicare Advantage Durable Medical Equipment Fraud Prevention

The Office of Inspector General (OIG) has released a report highlighting significant vulnerabilities in how Medicare Advantage Organizations (MAOs) and the Centers for Medicare & Medicaid Services (CMS) prevent fraud related to Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS). The OIG found that while MAOs and CMS implement measures to screen fraudulent suppliers, these efforts contain gaps that bad actors can exploit. Specifically, MAOs conduct fewer screening checks on out-of-network DMEPOS suppliers compared to in-network ones. Furthermore, CMS does not screen all DMEPOS suppliers before they bill Medicare Advantage, as not all of them are enrolled in Medicare. The report also notes limitations in CMS's Preclusion List, a tool designed to prevent certain suppliers from billing Medicare Advantage. Suppliers that bill out-of-network and are not enrolled in Medicare pose the highest fraud risk to the program. This issue is particularly critical given the substantial growth in Medica...

Representatives Introduce Bipartisan Bill to Permanently Authorize Rare Pediatric Disease Priority Review Voucher Program

Representatives Introduce Bipartisan Bill to Permanently Authorize Rare Pediatric Disease Priority Review Voucher Program

U.S. Representatives Gus Bilirakis (R-FL), Nanette Barragán (D-CA), Kat Cammack (R-FL), Jake Auchincloss (D-MA), Tom Kean, Jr. (R-NJ), and Kevin Mullin (D-CA) have introduced bipartisan legislation to permanently authorize the U.S. Food and Drug Administration’s (FDA) Rare Pediatric Disease Priority Review Voucher (PRV) Program. This program, established in 2012, incentivizes the development of treatments for children suffering from rare and devastating diseases. The PRV program awards a transferable priority review voucher to companies that successfully develop and receive FDA approval for qualifying treatments. Since its inception, the program has facilitated the market entry of treatments for 47 rare pediatric diseases, a significant increase from the four FDA-approved treatments that existed before the program. The current authorization for the program is set to expire in 2029. The proposed permanent authorization aims to provide long-term certainty for researchers and investors, encouraging continued ...

Medicare Part D Plans Face Increased Financial Risk and Declining Options for Beneficiaries

Medicare Part D Plans Face Increased Financial Risk and Declining Options for Beneficiaries

Medicare's stand-alone prescription drug plans (PDPs) are experiencing significant challenges, including higher premiums and a substantial reduction in available options for beneficiaries. Between 2023 and 2026, the number of PDPs decreased by 55%, from 804 to 360 plans. This decline is partly attributed to the Inflation Reduction Act of 2022 (IRA), which restructured Part D benefits. The IRA increased the generosity of standard benefits, improving affordability for many but also leading to higher drug spending. Additionally, the IRA shifted greater financial liability to Part D plan sponsors, making their benefit costs less predictable. In 2025, Medicare significantly reduced its reinsurance payments to plans while increasing direct-subsidy payments, forcing plans to bear risk on 60% of brand-name drug spending above the out-of-pocket (OOP) cap, compared to 15% previously. This change, coupled with a lowered OOP cap, has created uncertainty for plans regarding future prescription fills and overall costs. ...

Chairman Griffith Leads Health Subcommittee Hearing on Medicare Payment Reform and Cybersecurity

Chairman Griffith Leads Health Subcommittee Hearing on Medicare Payment Reform and Cybersecurity

Congressman Morgan Griffith (VA-09), Chairman of the Subcommittee on Health, delivered an opening statement at a hearing titled 'Examining Legislative Proposals to Reform Medicare Provider Payment and Bolster Health Care Cybersecurity.' The hearing focused on several bills aimed at addressing challenges within the Medicare physician fee schedule and enhancing cybersecurity in the healthcare sector. Griffith emphasized the need to improve the Medicare payment system to provide greater stability for healthcare providers, particularly independent and rural practices facing payment uncertainty and regulatory complexity. Key legislative proposals discussed included the 'Patients First Act' to modernize physician payment, the 'Provider Reimbursement Stability Act' to improve payment predictability, and the 'Ensuring Community Access to Pharmacist Services Act' to expand Medicare coverage for pharmacist services. Additionally, bills like the 'Alzheimer’s Screening and Prevention Act' and the 'Rural Obstetrics Rea...

Trump Administration's Medicaid Drug Price Promise Faces Delays and Uncertainties

Trump Administration's Medicaid Drug Price Promise Faces Delays and Uncertainties

The Trump administration's promise to lower drug prices in Medicaid through 'most-favored-nation' deals with pharmaceutical companies is facing significant delays and uncertainties. President Trump had announced in September of last year that companies like Pfizer would offer all their prescription medications to Medicaid at these discounted prices, expecting a substantial reduction in costs. However, NPR pharmaceuticals correspondent Sydney Lupkin reports that neither Pfizer nor 16 other major drug companies have confirmed that all their drugs would be discounted, nor have they specified the number of discounted drugs. The federal agency overseeing Medicaid also declined to provide this information. The initiative is structured as a voluntary pilot program, requiring each state to opt-in and agree to specific conditions, but the ramp-up has been slow, with states now having until September 30 to sign binding agreements.

Representative Michelle Fischbach Introduces 'Empowering Moms Act' to Centralize Maternal Resources

Representative Michelle Fischbach Introduces 'Empowering Moms Act' to Centralize Maternal Resources

Representative Michelle Fischbach introduced H.R. 10356, known as the 'Empowering Moms Act,' on September 14, 2026. This bill mandates the Department of Health and Human Services to update and maintain a federal website, moms.gov, within one year. The website is intended to serve as a comprehensive directory of resources for pregnant women, new mothers, and those raising young children. Key features of the site would include a searchable clearinghouse of resources, the ability for users to generate tailored resource lists based on their ZIP code, and options to filter resources by distance. The platform would also support multiple languages to enhance accessibility and allow users to consent to follow-up communications for additional resource sharing. The bill invites states to recommend resources and provides grants to help states build or support systems for collecting and organizing these resources. The types of resources covered are broad, encompassing medical, financial, educational, mental health, an...

Representative John Joyce Co-Introduces SECURE 340B Act to Address Drug Discount Program Concerns

Representative John Joyce Co-Introduces SECURE 340B Act to Address Drug Discount Program Concerns

U.S. Representative John Joyce from Pennsylvania, alongside Representative Scott Peters, has introduced the SECURE 340B Act. This legislative effort aims to bring greater transparency and oversight to the 340B Drug Pricing Program. The program, established in 1992, requires pharmaceutical manufacturers to provide outpatient drugs to eligible healthcare organizations and pharmacies at significantly reduced prices. The SECURE 340B Act seeks to address concerns regarding the program's rapid growth and the reported $100 billion in annual 340B purchases. The legislation is designed to ensure that the discounts provided through the program are directly benefiting vulnerable patients, as originally intended. It also looks to clarify the roles and responsibilities of various entities involved in the 340B program, including covered entities, contract pharmacies, and drug manufacturers, to prevent potential abuses and ensure compliance with federal guidelines. The introduction of this act signals a bipartisan effort...