Medicare Advantage Company Pays $342M to Government in Midst of Billing Probe

A major Medicare Advantage company has paid the government more than $342 million to help settle allegations that it overcharged the federal healthcare program for years.

Elevance Health, which covers about 2 million people on Medicare, sent the money to the Centers for Medicare & Medicaid Services via wire transfer on May 27, court records show. Government lawyers disclosed the payment in a June 22 court filing.

In an email to CMS staff, Elevance described the money as a “remittance of the total overpayment amount” estimated by government audits, court records show. Company spokesperson Leslie Porras told KFF Health News in a statement that Elevance Health “continues to engage in constructive dialogue” with CMS. “We remain optimistic that a resolution can be reached and value our longstanding relationship with CMS,” she said.

The payment was made in response to a CMS enforcement action in February, in which the agency threatened to halt enrollments in Elevance Medicare Advantage plans unless the company corrected what CMS called “substantial and persistent noncompliance” with federal regulations that require health plans to submit accurate billing data and return any overpayments when they are discovered.

It appears to be the first time CMS has successfully pressured a Medicare Advantage health plan to pay back tens of millions of dollars in alleged overpayments — even though agency officials have known for years that many health plans have overbilled the program, according to audits by government staff.

“I’ve never heard of something like this before,” said David Lipschutz, an attorney with the Center for Medicare Advocacy, a nonprofit public interest law firm. “Usually plans seem to tie everything up and try to delay any repayment of anything for years.”

David Meyers, an associate professor at the Brown University School of Public Health, called the payment “substantial” and “a step in the right direction” toward holding the industry accountable.

“It’s a big win for CMS to get that much,” he said.

More than 35 million Americans, about 55% of people on Medicare, have signed up for the private Advantage health insurance plans, which offer extra benefits, such as hearing aids and dental coverage, that traditional Medicare doesn’t cover.

Joining the plans may also prove cheaper for patients than purchasing a supplemental insurance policy that covers gaps in traditional Medicare.

Whether Medicare Advantage is a good deal for taxpayers is hotly debated, however.

The health plans have been the target of dozens of whistleblower lawsuits and government investigations alleging they often exaggerate how sick patients are to improperly boost their payments, claims the industry disputes. Medicare pays health plans higher rates for sicker patients but requires that the plans bill only for conditions that are properly documented in a patient’s medical records.

Researchers also have concluded that Medicare overpays the health plans by billions of dollars every year because of medical coding flaws that generate higher bills than are justified.

The whistleblower suits, mostly filed by former employees of healthcare companies, have long served as the primary tool for clawing back alleged overpayments. In January, Kaiser Permanente agreed to pay $556 million to settle Justice Department allegations that it billed the government for medical conditions patients didn’t have, the largest such penalty to date. In a statement posted on its website, the company said it settled the case “to avoid the delay, uncertainty, and cost of prolonged litigation.”

By contrast, CMS’ efforts to prevent Medicare Advantage plans from overcharging have largely foundered.

In 2014, for instance, CMS backed off a proposed regulation that would have cracked down on overbilling amid an “uproar” of opposition from the industry. And even when CMS audits uncovered tens of millions of dollars in overpayments, agency officials collected only a tiny fraction of that amount.

The CMS threat to bar Elevance from enrolling new members may open a new approach.

“The payment Elevance is making here is not trivial,” said Matthew Fiedler, a health policy researcher at the Brookings Institution.

But he noted that it represents a very small fraction of the total the company receives from Medicare. He said that making a big dent in the overpayment problem would require CMS to collect “many similar payments” — from “every” Medicare Advantage insurer.

“I don’t think there’s a clear reason to believe that at this stage,” Fiedler said.

Richard Kronick, a former federal health policy official and a professor at the University of California-San Diego, agreed that the payment reflects a small portion of the company’s revenue. But he said it was “still a sizable check to write.”

Kronick said the action reflects “perhaps a bit of muscle flexing” by CMS to tighten up enforcement.

CMS did not immediately respond to a request for comment. It’s not clear from court records whether the payment will end the CMS threat to ban Elevance from signing up new members.

If so, it might prove to be a relative bargain. In an April filing with the Securities and Exchange Commission, the company noted that its “current best estimate” of the “potential exposure” in the case was approximately $935 million.

Elevance has been at odds with the federal government over its billing practices since 2020, when the Justice Department filed a False Claims Act lawsuit against the company, then known as Anthem. That case is pending.

Court filings in that case disclosed the company’s payment to CMS. In an email made part of the court file, a company official confirmed it had sent the wire transfer in the amount of $342,209,085.30 on May 27 and said the payment was related to the threatened enrollment ban. The company also stated that it was challenging the CMS enforcement action and called it “unprecedented.”

In defending against the Justice Department suit, Elevance has denied wrongdoing and argued that CMS knew about its billing practices for years and took no action.

Meyers, the Brown University professor, said CMS’ success in collecting payment from Elevance may encourage more enforcement.

“It remains to be seen whether this is a sea change,” he said.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

This <a target="_blank" href="https://kffhealthnews.org/medicare/medicare-advantage-cms-elevance-crackdown-overcharging-payment/">article</a&gt; first appeared on <a target="_blank" href="https://kffhealthnews.org">KFF Health News</a> and is republished here under a <a target="_blank" href="https://creativecommons.org/licenses/by-nc-nd/4.0/">Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="https://kffhealthnews.org/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

<img id="republication-tracker-tool-source" src="https://kffhealthnews.org/?republication-pixel=true&post=2254145&amp;ga4=G-J74WWTKFM0&quot; style="width:1px;height:1px;">

from KFF Health News https://ift.tt/uLVeWjC

Read More

Fortis Hospital faces action after Delhi govt inquiry finds multiple irregularities

Acting on CM’s directions, a team led by central-north district magistrate S S Parihar, along with officials from the health department, MCD, fire department and other agencies, inspected the hospital Thursday.

from Top Health News | Latest Healthcare Sector & Healthcare Industry news, Information and Updates: ET HealthWorld : ETHealthworld.com https://ift.tt/Fve2W5o

Read More

Study of gut microbiomes reveals link between low fibre intake, colorectal cancer

Findings published in the journal Cell Host and Microbe suggest that diet, especially consuming fibre, can influence colorectal cancer risk, progression or prevention by shaping gut microbial communities.

from Top Health News | Latest Healthcare Sector & Healthcare Industry news, Information and Updates: ET HealthWorld : ETHealthworld.com https://ift.tt/amX9wPp

Read More

Democrats To Propose Bill Capping Out-of-Pocket Medicare Costs for Enrollees

Sen. Ron Wyden and 14 Democratic co-sponsors plan to introduce legislation Thursday to cap consumers’ potential out-of-pocket costs in traditional Medicare, resurfacing a long-running debate over why the program doesn’t limit beneficiary spending.

Even the bill’s backers say securing passage this year is a long shot. But the effort is one more opportunity for Democrats to highlight voters’ frustration about healthcare costs leading into the November election.

Polls show Americans are very concerned about affordability, with a recent Gallup survey finding fewer than half of Americans say they can consistently afford healthcare.

Wyden’s bill would focus on what many consider a critical pocketbook issue in traditional Medicare: There’s no limit on what a beneficiary could pay in cost sharing.

“Everyone else in the health insurance neighborhood has one — employer coverage, the Affordable Care Act, all of them have a cap,” the Oregon Democrat told KFF Health News. “There’s no good, common-sense reason why the flagship health program doesn’t have the same protection.”

Critics of a cap, meanwhile, are likely to pounce on the cost to the federal budget, which could be significant.

Wyden, already making the battle lines clear, added, “I suspect it will come up on the floor of the Senate that Democrats want to give a fair shake to people on traditional Medicare and Republicans want to help billionaires.”

Policy, Political Dynamics at Work

The underlying issue is the 20% share of Medicare costs that enrollees have to pay for medical services after they’ve met any deductibles. Without a ceiling or upper limit, an expensive condition such as cancer or a long hospital stay could result in beneficiaries paying thousands of dollars in costs.

That concern leads about 43% of people enrolled in traditional Medicare to purchase separate insurance, often called Medigap. (Others get such coverage through job-based retiree plans.)

Medigap insurance plans have seen rapid premium increases and can cost thousands of dollars a year, especially for couples. That price tag can be unaffordable for some beneficiaries, who may instead turn to private-sector Medicare Advantage plans offered by commercial insurers, or go without.

The Wyden proposal would set a $5,000 cap in traditional Medicare. Any amounts paid by a Medigap plan or a retiree health plan toward beneficiaries’ care would count toward that cap. It also includes other provisions to help older people with lower incomes, including eliminating an asset test to qualify for special programs that help reduce costs.

Medicare would pick up any amounts over that $5,000 limit, which is lower than the one Congress set for the rival Advantage plans — currently $9,250, although insurers can set smaller amounts.

Setting a cap in the traditional program, proponents argue, would help level the playing field between traditional Medicare and Advantage plans, which often cost consumers far less than traditional Medicare with a Medigap supplement. Premiums for these policies would probably be lower, they say, because the insurers’ financial exposure would be limited.

The Medicare Advantage program has historically had strong support from Republicans, who like its private-sector aspect and note that it can potentially do more to control costs, such as by using specific networks of doctors and hospitals, or requiring preapproval for some services, which the traditional program cannot do.

The plans also offer enrollees additional benefits, such as eyeglasses, hearing aids, and prescription drug coverage, and have now attracted more than half of all Medicare enrollees.

Along with that growth, however, has also come increased scrutiny over concerns about denials of patient services and the challenges some consumers face if they want to switch back to the traditional program. Recently, some health systems have dropped out of Medicare Advantage contracts, citing concerns about tardy payments or prior authorization requirements, while insurers are also scaling back where they offer Advantage coverage.

The bill has not yet been analyzed by the Congressional Budget Office, so there is no official estimate of increased costs to taxpayers for Medicare. Still, it would raise those costs — at a time when other health programs are being cut, the Medicare trust fund is scheduled to start falling short of funding in 2033, and the nation’s debt is growing.

That is likely to draw sharp rebukes from fiscal hawks and other conservatives who question whether billions in tax dollars should be used to pick up costs that would otherwise be paid by enrollees or by the supplemental insurance plans many purchase to do so. They are likely to note that beneficiaries could also choose to join private sector Advantage plans, which eliminate the need for supplementary insurance coverage such as Medigap.

Key Questions: Who Benefits? Who Pays?

A cap’s cost to taxpayers, while not officially scored yet, is likely to be significant, although adding one could also save individual consumers money. A recent study from Brown University gives some clues.

A $5,000 cap could save enrollees an average of about $1,200 a year, the study says, both in direct savings and reductions in their Medigap supplemental premiums. Just over 11% of traditional Medicare beneficiaries, about 3.2 million, would directly benefit from such a cap if it was implemented in 2028, said the study, which did not receive outside funding.

Over the next 10 years, it estimates, just over 52% of all traditional beneficiaries would exceed the $5,000 cap at least once.

Still, lead author Andrew Ryan, a professor at Brown’s School of Public Health, said analysts estimated such a cap “could cost over $50 billion annually, which is a lot of money” to add to the federal balance sheet.

Critics are likely to focus on the cap’s expense and the number of people who might benefit.

“How many people are hitting a level of cost they can’t afford on Medicare? “asked Jackson Hammond, a senior policy analyst with the Paragon Health Institute, a conservative think tank influential with the GOP.

Any cap “is generally going to increase expenses for the program without adding a lot of benefits to enrollees,” said Hammond, who spoke with KFF Health News before the legislation was introduced.

Supporters, though, have a different view.

Certainly, with “any policy that’s going to cost money, there will be an argument over where the money is coming from,” said Brian Keyser, a research associate at the liberal Center for American Progress who also spoke with KFF Health News before the Wyden measure was introduced.

Keyser co-authored a Medicare paper that suggested lawmakers could pay for changes in traditional Medicare, such as an out-of-pocket cap, if they reduced the amount the government pays Medicare Advantage insurers, pointing to government estimates that Advantage would cost the government $76 billion more this year than if the same number of people were in the traditional program.

Finding a way to add a cap “is right and fair because without it, people who become seriously ill can spend their life savings on cost-sharing Medicare,” Keyser said.

Such an idea, however, has been in discussion on and off for years. Knowing that, the bill’s backers acknowledge that passage is unlikely — but they say they’re playing the long game for now.

“We’re going to push for it in the next Congress, when we believe we will be in the majority,” Wyden said.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

This <a target="_blank" href="https://kffhealthnews.org/medicare/medicare-costs-out-of-pocket-cap-democrats-senate-wyden-midterms/">article</a&gt; first appeared on <a target="_blank" href="https://kffhealthnews.org">KFF Health News</a> and is republished here under a <a target="_blank" href="https://creativecommons.org/licenses/by-nc-nd/4.0/">Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="https://kffhealthnews.org/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

<img id="republication-tracker-tool-source" src="https://kffhealthnews.org/?republication-pixel=true&post=2253723&amp;ga4=G-J74WWTKFM0&quot; style="width:1px;height:1px;">

from KFF Health News https://ift.tt/uOZVejH

Read More

Global Ebola risk 'remains low', WHO chief says

France on Wednesday announced its first confirmed case of Ebola identified on its territory: a doctor who had flown back from the DR Congo, which is fighting a major outbreak.

from Top Health News | Latest Healthcare Sector & Healthcare Industry news, Information and Updates: ET HealthWorld : ETHealthworld.com https://ift.tt/knfvjKY

Read More

Indian Pharmacopoeia becomes first in world to establish standards for blood

A pharmacopoeia is an official compendium of quality standards of the drugs being imported, manufactured for sale, stocked or exhibited for sale or distributed in a country. The pharmacopoeial monographs prescribe standards to ensure the identity, purity and strength of the given drugs through botanical identification, various physico-chemical parameters and the like.

from Top Health News | Latest Healthcare Sector & Healthcare Industry news, Information and Updates: ET HealthWorld : ETHealthworld.com https://ift.tt/kMZNj30

Read More

Even in Blue States, Hospitals Have Continued To Drop Gender-Affirming Care for Youths

One afternoon in late 2024, a sixth-grader nicknamed Bug came home from school with an announcement to make. Bug, who was assigned female at birth, told his parents he was a boy — and would be using he/him pronouns.

“OK, cool,” his mother, J, remembered saying. (J asked to be identified by only her first initial, and Bug by his nickname, because the family fears harassment.)

“‘What do you need to be supported?’” she recalled asking next. “He asked to get healthcare.” 

This was the kind of moment J had been anticipating since the family had moved earlier that year from Texas to Massachusetts, for its more liberal and inclusive politics. She felt confident they could find the right medical experts. But she hadn’t realized that access to gender-affirming treatment could disappear even when their state’s laws and leaders supported it.

Individual hospitals all over the U.S., in red and blue states, have responded to President Donald Trump’s attacks on transgender healthcare by deciding to withdraw care on their own. At least 20 hospitals did so in the first months of the Trump administration as it threatened to pull back federal funding or initiate fraud or wrongful-claim investigations, and such services have continued to drop off since.

Bug and his younger sister were born in Austin, Texas, but J and her husband became worried after the state outlawed abortion; dismantled diversity, equity, and inclusion programs; and limited medical and civil rights for queer and transgender people. The parents worried the support services they needed for the siblings, both of whom have autism, might be affected, too.

“I had a fear of being like the frog in the boiling water and not realizing what was happening until it was too late,” J said. “I needed to get the kids out of Texas.”

So when Bug came out as trans, J was relieved they’d landed in a state that not only has a “shield” law to protect providers who offer gender-affirming care but also is among 24 states requiring commercial insurance, which Bug’s family has, to cover it.

After Bug’s gender announcement, J’s queries led her to the largest hospital system in the region, Springfield, Massachusetts-based Baystate Health, where they began the months-long process of getting set up to start hormone therapy.

Bug, an artistic 14-year-old who loves horses, cats, and making short films with friends, was too old for puberty blockers, but he was excited about the prospect of starting on testosterone. That would cause his voice to deepen, facial hair to grow, and muscles to get bigger.

“Every part of it sounds fun,” he said.

J (right) and her son, Bug, at their home in western Massachusetts. Bug, who came out as a trans boy in 2024, had turned to Baystate Health for treatment until the health system stopped providing gender-affirming medications to youths. (Karen Brown/New England Public Media)

But this past February, two weeks before Bug was scheduled to start testosterone, Baystate announced it would no longer provide gender-affirming medications to minors, offering only counseling. A letter to patients’ families did not explain why.

Baystate spokesperson Heather Duggan sent a statement that said the decision to end treatment for minors reflected the fact that Baystate could lose “hundreds of millions of dollars in government reimbursement” as a result of the Trump administration’s plans. “Nearly 70 percent of Baystate Health’s patients rely on Medicaid and Medicare for coverage,” it said.

All Bug knew was that the care he’d eagerly awaited was about to vanish.

“I felt frustrated that they would do that,” Bug said.

“I bet there’s tons and tons of kids who are like: ‘OK, I’m going for trans-affirming healthcare. Yay!’” he said. “And then, like, tons and tons of kids were disappointed and sad and frustrated.”

J said it felt as if the floor had fallen out from under them. “Maybe this is naive, but I didn’t think that would happen in Massachusetts,” she said.

Baystate is among the providers still choosing not to offer puberty blockers and hormones as the issue wends its way through the courts. This spring, in a lawsuit that Massachusetts joined, a federal judge concluded that it was unlawful for the Department of Health and Human Services to threaten federal funding for providers that offered gender-affirming care to minors. In June, another federal judge cleared 16 states, including Massachusetts, to move forward with another lawsuit against the administration over its push to criminalize gender-affirming care.

Baystate Medical Center in Springfield, Massachusetts. The Baystate Health system stopped providing gender-affirming medications to youths in February, after the Trump administration said it would pull Medicaid and Medicare funding from hospitals providing them. (Karen Brown/New England Public Media)

The American Academy of Pediatrics declined an interview request but said in a past statement that young patients and their families should make decisions about gender-affirming care with their doctors, “delivered with compassion, and offered without political interference.”

One mother of a former Baystate patient said that before her child came out as a transgender girl, she had been severely depressed, battling suicidal thoughts. (The mother asked that only her first initial, L, be used, because the family also fears harassment.)

After Baystate doctors prescribed puberty blockers and estrogen, her daughter’s mood and grades rose markedly, L said. So when she received the letter announcing Baystate was ending the medical treatment, she was furious. L said she and other parents filed civil rights complaints with the Massachusetts attorney general.

The attorney general’s office did not respond to a request for comment.

“There’s a sense of, ‘How could you?’” L said. “And there’s also the awareness of the impact just pulling care could have on a youth — from a physical health perspective but also from a mental health perspective.”

L and J both found alternatives for their children. L asked the family’s primary care doctor to take over hormone prescriptions. Bug’s family was referred to Transhealth, a private specialty clinic in Northampton, Massachusetts, that said it has taken on about 50 of Baystate’s former patients.

“Transhealth has been staffing ourselves up for a while now in anticipation of the fact that this may be happening across the state,” CEO Jo Erwin said.

Erwin said Transhealth can weather the funding threats because the clinic gets large private donations and is not as dependent on Medicaid and Medicare as most hospitals. But Erwin said that doesn’t entirely reassure the broader LGBTQ+ community, including transgender adults.

“When you see something like that go down, people get scared that it’s ultimately going to happen to everyone,” Erwin said.

In May, Colorado’s Supreme Court ordered a children’s hospital in that state to resume medical treatments for transgender youths, while in Texas a court settlement compelled a children’s hospital there to do the opposite — start the nation’s first “detransition clinic.” The Trump administration has continued to pressure providers, including by seeking the medical records of transgender minors.

After Bug’s false start at Baystate, he was able to start taking testosterone at the new clinic in the spring.

His mother, J, said that the treatment is going smoothly and that Bug has learned how to give himself the injections. But J is nervous that the federal government will find other ways to stop his treatment again. She sometimes second-guesses the family’s move from Texas to Massachusetts, wondering whether they should have gone to Canada instead.

This article is from a partnership that includes New England Public Media, NPR, and KFF Health News.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

This <a target="_blank" href="https://kffhealthnews.org/health-industry/gender-affirming-care-trump-hospitals-transgender-massachusetts/">article</a&gt; first appeared on <a target="_blank" href="https://kffhealthnews.org">KFF Health News</a> and is republished here under a <a target="_blank" href="https://creativecommons.org/licenses/by-nc-nd/4.0/">Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="https://kffhealthnews.org/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

<img id="republication-tracker-tool-source" src="https://kffhealthnews.org/?republication-pixel=true&post=2252159&amp;ga4=G-J74WWTKFM0&quot; style="width:1px;height:1px;">

from KFF Health News https://ift.tt/3wfvQUV

Read More

Flu kills 1.2 lakh/year in India, senior citizens bear the brunt

Recent findings show that a mere 2% of senior citizens in India are vaccinated against influenza, which accounts for approximately 1.2 lakh deaths each year. This significant gap in adult vaccination extends to other vital diseases, such as pneumococcal infections and hepatitis B, which also see concerningly low uptake rates.

from Top Health News | Latest Healthcare Sector & Healthcare Industry news, Information and Updates: ET HealthWorld : ETHealthworld.com https://ift.tt/Ch6tfk1

Read More

Centre seeks Industry feedback over revision of GTE-Exempt Medical device list

The GTE exemption list allows public agencies to procure products that are not locally produced in the country. The process of revising the current list of 354 devices began in February this year, when manufacturers submitted proposals for additions and deletions for the next cycle.

from Top Health News | Latest Healthcare Sector & Healthcare Industry news, Information and Updates: ET HealthWorld : ETHealthworld.com https://ift.tt/lEUg0x7

Read More

Medicare’s AI Push Snarls Patients and Doctors in Errors and Delays

Bill Curry, 65, raises cattle on the same land in rural Oklahoma once owned by his father and generations before him. Each quarter, for several years, he has made the 2½-hour drive to Oklahoma City for an epidural in his spine to treat his back pain.

But this year, because of a new Medicare program, Curry has traveled a little more often.

In February, during one trip, he was told unexpectedly that he needed preapproval for the procedure. Then he went again a month or so later to get the injection, for a total of 10 hours on the road. His clinic wanted him to come in a third time, which they had never asked of him before. That appointment was “just to fill out a piece of paper to tell them how you feel again,” Curry said, so he hasn’t gone.

In January, Oklahoma became one of six states to begin a pilot program testing the use of preapprovals in traditional Medicare, the federal health insurance program for people 65 and older or with disabilities. Medicare had previously eschewed the practice — also known as prior authorization — which requires patients or someone on their medical team to seek insurance approval before proceeding with certain procedures, tests, and prescriptions.

Epidurals like Curry’s are among 13 medical services subject to the new program because the Trump administration says they’re prone to fraud or misuse. Powered by artificial intelligence, the program — called the Wasteful and Inappropriate Service Reduction Model, or WISeR — is intended to save the federal government money and protect patients from potentially unsafe or unneeded care.

Yet early reviews from Oklahoma and the other pilot states — Arizona, New Jersey, Ohio, Texas, and Washington — suggest WISeR’s rollout has not been smooth. Patients, doctors, and other healthcare professionals who spoke with KFF Health News say the effort has created confusion, errors, long wait times, and stress. Some described the rollout as “horrendous” and say people enrolled in Medicare in the pilot states are now getting ensnared in the same red tape as those with private insurance.

One key concern is that it all happened too hastily. WISeR was announced in June 2025 and launched in mid-January.

That was “quicker than normal” for the federal government, said Todd Baker, who recently stepped down as CEO of the Ohio State Medical Association. Doctors “just sort of had to figure it out,” added Jeb Shepard, director of policy at the Washington State Medical Association.

Government contractors have also acknowledged the rapid pace. “We’ve had an aggressive rollout from the time of being notified to going live,” said Jeremy Friese, CEO of Humata Health, the vendor for Oklahoma. Tech executives servicing other states have said they were still adding features to their products in the spring.

Abe Sutton, director of the Center for Medicare and Medicaid Innovation, which is administering the program, didn’t comment on the rollout schedule. But he said in a statement that the goal of these reforms is to ensure that prior authorization is efficient, fast, and streamlined.

“The model aims to reduce inappropriate care without delaying appropriate care,” he said.

Mehmet Oz, the leader of the Centers for Medicare & Medicaid Services, told NewsNation in December that they were “rolling out some prior authorization on abused practices.”

“The purpose of these is not to deny care,” Oz continued. “It’s to make sure you get the care you need and deserve, not the care some unscrupulous doctor wants to use on you.”

Medicare has struggled in recent years with suspected fraud associated with particular services. The Department of Health and Human Services’ inspector general warned in September that the program’s spending on skin substitutes, for example, had surged nearly 700% over two years, raising “major concerns about fraud, waste, and abuse.” Skin substitutes are among the 13 therapies currently subject to review under WISeR.

The program also imposes prior authorization requirements for kyphoplasty, a surgery for spinal fractures, which a report by the Medicare Payment Advisory Commission flagged as overused.

Sutton acknowledged, however, that “the percentage of providers committing waste, fraud, and abuse is small.”

Consumers and clinicians largely detest prior authorization. Even as federal health officials test the process for Medicare, the Trump administration is trying to scale it back for those with private insurance. According to a KFF poll conducted in January, 69% of insured adults consider prior authorization a burden for care.

Through WISeR, doctors and their staff log in to online portals to submit medical records that justify the procedures. Using artificial intelligence, the systems quickly approve applications that meet the program’s criteria, Friese, Humata’s chief executive, told KFF Health News. He said there is an “immediate yes” in 88% of cases for which clinical data supports an approval.

CMS has touted the process as one in which decisions are returned within 72 hours. After that, clinicians receive a “universal tracking number,” which allows them to schedule the procedure and get paid. In practice, however, participants say the process is anything but easy.

The University of Washington’s medical system alone had nearly 100 patients waiting earlier this year for epidural injections due to WISeR-related delays, according to an April report from the office of U.S. Sen. Maria Cantwell (D-Wash.) that drew on hospital association data. “Now, patients are subject to delays or denials which did not exist prior to the WISeR Model,” the report said.

Curry, the Oklahoma cattle farmer, said he might go to Kansas for future treatments to avoid the approval process. Dorota Gribbin, a New Jersey-based physical medicine and rehabilitation physician, said that by the time authorization came for one of her patients who needed a back pain procedure, the patient had gone to the hospital for more expensive care.

Jennifer Valle, a precertification and insurance supervisor at Clinical Radiology of Oklahoma, said when it comes to kyphoplasties, there has been a lot of “nitpicking” from reviewers. Other times, information her practice provides to CMS gets overlooked, she said, and reviewers ask for imaging that’s already in the file.

Claims with no problems are supposed to be paid within 15 days, said James Webb, a musculoskeletal radiologist in Tulsa, Oklahoma, who has also been frustrated by the prior approval and reimbursement process for kyphoplasties. “Six- to eight-week delays is what we’ve been seeing,” he said.

“It’s been horrendous,” said Jerry Sobel, a Phoenix-area pain management doctor. “Right from the beginning, there seemed to be no organization.” Sobel said that as of May, he hadn’t gotten paid by Medicare for nine epidurals.

“We continuously monitor operations and work closely with stakeholders to address questions and improve the provider experience,” said Sundar Subramanian, the CEO of Zyter, which has the contract for Arizona.

During an April webinar, another Zyter executive acknowledged a large backlog in payments stretching to January. Those backlogs “are currently being resolved,” Medicare’s Sutton said, without providing further detail.

When asked about other issues — including what doctors suspect are AI-driven errors — Medicare’s Sutton said the agency appreciates “feedback on provider experience.” It will be used “to help providers better understand WISeR processes,” he said.

Although CMS vendors say humans make the final decisions on approvals, doctors and their staffs believe artificial intelligence is playing a large role in the process and that denials are sometimes the result of AI hallucinations that garble or make up information.

One Arizona doctor, who wasn’t authorized by his practice to speak, recalled a denial saying his patient wasn’t eligible for procedures in the thoracic region, or mid-back. The patient needed an injection to the neck. Webb, the Oklahoma radiologist, documented four times that a patient lacked numbness, and yet his WISeR application was still denied, citing numbness, which, in the reviewer’s interpretation, would rule out the spinal surgery procedure.

Friese, Humata’s CEO, said he hasn’t heard about any AI hallucinations.

The process is also raising government costs. With more rejections, more appeals are being filed with Medicare’s administrative contractors. The government pays the contractors to handle the appeals, and Medicare’s Sutton acknowledged that the agency has “accounted for potential changes in the volume of Medicare appeals because of the WISeR program and its associated costs.”

Eighty-four percent of commercial insurers already use AI tools, according to a survey released in 2025 by the National Association of Insurance Commissioners, though they have consistently said AI isn’t used to deny prior authorization requests.

Its use in Medicare risks introducing friction and frustration into the program — and piling costs onto its beneficiaries. Prior authorization saves money for insurers partly by making patients pay a price in wait times and inconvenience, said Miranda Yaver, a University of Pittsburgh health policy researcher studying the technique.

“People will end up getting ensnared in a lot of red tape, having to be on hold, and getting rerouted,” she said. She often wonders whether prior authorization simply shifts costs to patients and doctors, rather than saving them.

Some doctors involved in Medicare’s prior authorization experiment believe it will inevitably expand beyond a few services officials in Washington consider fraud-prone.

“Everybody knows that if this pilot project works, it will be prior auth for basically all procedures,” said Mary Clarke, a family practice physician in Stillwater, Oklahoma. “If they can show that they can save money, then that’s going to be extrapolated and rolled out to other procedures and multiple other things in other states.”

When asked whether CMS is considering expansion of its prior authorization pilot, Sutton said in his statement that there are “currently no changes” considered for the list of services subject to the WISeR program, “but CMS continues to assess whether any changes are warranted.”

Do you have an experience with prior authorization you’d like to share? Click here to tell KFF Health News your story.

KFF Health News Southern correspondent Lauren Sausser contributed to this report.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

This <a target="_blank" href="https://kffhealthnews.org/medicare/medicare-ai-prior-authorization-wiser-delays-errors/">article</a&gt; first appeared on <a target="_blank" href="https://kffhealthnews.org">KFF Health News</a> and is republished here under a <a target="_blank" href="https://creativecommons.org/licenses/by-nc-nd/4.0/">Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="https://kffhealthnews.org/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

<img id="republication-tracker-tool-source" src="https://kffhealthnews.org/?republication-pixel=true&post=2251634&amp;ga4=G-J74WWTKFM0&quot; style="width:1px;height:1px;">

from KFF Health News https://ift.tt/jQpzlVd

Read More