For much of his life, Bill Curry has raised cattle on family land in rural Oklahoma. For years the 65-year-old made the two-and-a-half-hour trek to Oklahoma City every few months for epidural injections to help manage chronic back pain.
But this year the pattern was different.
When Curry came in for a visit in February, he was told that his treatment now needed prior authorisation under a new Medicare pilot programme. Weeks later he came back for the injection, another long journey there and back. He said a third visit was requested to complete more paperwork, something that had never been required before.
“I haven’t gone,” Curry said, adding the appointment seemed to be just to fill out forms.
Oklahoma is one of six states participating in a new Medicare pilot program called the Wasteful and Inappropriate Service Reduction (WISeR) Model. The initiative, which began in January, requires prior authorisation for certain procedures in the traditional Medicare system, which did not previously require such authorisations.
The program is designed to reduce unnecessary care, reduce fraud, and make patients safer, according to the Centers for Medicare & Medicaid Services. Currently thirteen services are under review, including epidural injections, skin substitutes and kyphoplasty procedures.
Artificial intelligence runs submitted clinical information to determine whether or not treatments fit program requirements. Officials say the technology can speed up decision-making and cut down on improper spending.
But initial experiences in Oklahoma, Arizona, New Jersey, Ohio, Texas and Washington suggest the implementation has been rocky.
Patients and healthcare providers are confused about new requirements, delays in approvals for treatment and growing administrative burdens. Medical groups in several states say the change came quickly and gave doctors little time to adjust.
Todd Baker, the former CEO of the Ohio State Medical Association, said the rollout of the program felt unusually rushed compared to typical federal initiatives. Jeb Shepard from the Washington State Medical Association added that many doctors were essentially left to figure out the new system on their own.
Even the technology companies responsible for running the program have admitted that they were working under tight deadlines. Jeremy Friese, CEO of Humata Health—which manages the system in Oklahoma—noted that his team had to meet an aggressive timeline before the program officially launched.
Federal officials, however, defend the program’s pace. Abe Sutton, who leads the Center for Medicare and Medicaid Innovation, said the intent is to cut down on unnecessary treatments while still making sure patients receive care when they truly need it.
According to CMS, many decisions are made within about 72 hours, and vendors say that cases that meet the required medical criteria are often approved automatically.
Still, doctors and healthcare providers say the system hasn’t always worked as smoothly as intended. An April report prepared for Senator Maria Cantwell of Washington revealed that nearly 100 patients in the University of Washington health system were waiting for epidural injections due to delays linked to the WISeR program. The report also pointed out that these types of delays or denials did not occur under the traditional Medicare system.
Doctors also say that these delays can sometimes end up costing more in the long run. Dorota Gribbin, a rehabilitation specialist in New Jersey, shared an example of a patient who had to go to the hospital after waiting too long for approval for a pain-management procedure.
The debate over WISeR highlights a larger issue across the healthcare system: prior authorisation. Insurance companies argue that these requirements help prevent unnecessary treatments and keep costs under control. But many doctors and patients see them differently—as barriers that can delay needed care.
A survey conducted by KFF in January found that most insured adults view prior authorisation as a burden rather than a benefit.
Federal officials, however, say some level of oversight is still important. They point out that spending on certain medical services under Medicare has risen sharply, and government watchdogs have flagged possible cases of overuse and even fraud in some treatments included in the program.
In the end, it’s still unclear whether WISeR will succeed in cutting down unnecessary care without creating new hurdles for patients. As the program moves forward, pressure is likely to grow on healthcare providers and government officials to find the right balance—preventing fraud while also ensuring that patients can get timely treatment when they need it most
