Traditional Medicare plan holders have typically not had to wait for prior authorization before receiving medical treatment.
Until now.
The Centers for Medicare & Medicaid Services (CMS) recently announced a new program to test prior authorization requirements for certain services in six states starting Jan. 1.
The states — New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington — will apply prior authorization evaluations to more than a dozen services.
CMS says the pilot program is intended to root out “fraud, waste, and abuse,” but as Medicare Advantage members know well, prior authorization can lead to frustrating delays in care.
How it works
CMS will contract with private companies to deploy “enhanced technologies, including artificial intelligence (AI)” to conduct the authorization reviews.
It won’t apply to in-patient or emergency services or treatments “that would pose a substantial risk to patients if significantly delayed,” according to a CMS press release. Specific services that will require prior authorization are skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy.
There is genuine concern about the costs of some of these items and services. A recent New York Times article highlighted pricey medical products, including paper-thin bandages made of dried bits of placenta, for Medicare patients.
Hellbound and Down 