The Wasteful and Inappropriate Service Reduction (WISeR) model has been launched by Medicare in certain states. The model involves the voluntary prior authorization (PA) of certain traditional Medicare Fee for Service (FFS) services including the use of CTPs/skin substitutes for diabetic foot ulcers (DFUs) and Venous Leg Ulcers (VLUs). (It is important to know that if you do not voluntarily submit a PA request, relevant claims will be subject to PRE-PAYMENT review!) WISeR will NOT impact the care provided in long term care settings, and it will not impact the use of CTPs in other ulcer types like pressure ulcers.
The Medicare Administrative Contractors (MACs) participating include- JH, JL, JF, and J15 and thus the States originally included were Ohio, Texas, New Jersey, Oklahoma, Washington, and Arizona. However, to implement the WISeR model, a state/MAC must have a Local Coverage Determination (LCD) in place for the service such as the application of CTPs, and with the repeal of the skin sub LCDs for DFUs and VLUs, Washington and Arizona have no active LCD. Thus, as far as I know, WISeR did not begin in Washington and Arizona as planned. However, the WISeR model should have started the first week of January for OH, TX, NJ, and OK.
One of the things that makes this project novel (besides the obvious fact that Medicare FFS charges are under prior authorization at all) is that CMS selected contractors to implement it with the specific intent of using artificial intelligence (AI) to review the medical records and evaluate whether the requirements of the relevant LCDs had been met. The use of AI makes this project novel for Medicare (although not for other payers, since we are well aware that the use of AI is becoming commonplace as part of PA among private payers).
Dr. Jay Shah, a well-known wound care practitioner, is currently the President of the Texas Medical Association (TMA). The TMA is among the most active and impactful state medical societies (I know that because I have spent my career practicing in Texas). The TMA is following the implementation of WISeR closely. Dr. Shah would appreciate learning more about clinician concerns regarding the WISeR project in Texas (for CTPs/skin subs but naturally for any of the listed services). If you email me with your experiences, I will make sure that your comments get to Dr. Shah and the TMA (cfife@intellicure.com). Please do not send me any PHI!
This is a rare and wonderful opportunity to have your voice heard by a powerful state medical association (with a president who is a wound care expert!) that can provide that feedback directly to the contractor in charge of implementing the WISeR model. This is particularly important given the fact that Medicare is testing the ability of AI to implement the details of an LCD!
–Caroline
Resources:
- CMS Prepares to Launch a Prior Authorization Model for “Skin Substitutes” in Traditional Medicare as Part of the WISeR Initiative – Caroline Fife M.D.
- Noridian Webinar Materials on Wasteful and Inappropriate Service Reduction (WISeR) Model – Caroline Fife M.D.
- Artificial Intelligence vs Augmented Intelligence in Prior Authorization Denials – Caroline Fife M.D.
- About the CMS Innovation Center | CMS
- (The summary below is partially excerpted from a more detailed review by Julie Rhodovi)
Dr. Fife is a world renowned wound care physician dedicated to improving patient outcomes through quality driven care. Please visit my blog at CarolineFifeMD.com and my Youtube channel at https://www.youtube.com/c/carolinefifemd/videos
The opinions, comments, and content expressed or implied in my statements are solely my own and do not necessarily reflect the position or views of Intellicure or any of the boards on which I serve.
