If you’ve purchased an insurance plan in the last 10-15 years, you’re probably familiar with the term “prior authorization.” Prior authorization is an administrative process insurance companies use to either authorize or deny coverage prior to medical procedures, weeding out procedures that may not be medically necessary.
If you are part of a Medicare Advantage plan, you are definitely familiar with the term and may have even found yourself on the wrong side of it, potentially having to appeal a decision. Traditional Medicare has historically not required “prior authorization,” but a new pilot program called WISer is studying the impact of prior authorization on certain services.
The Wasteful and Inappropriate Services Reduction is a six-year pilot program in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington. The program aims to eliminate fraud, waste and abuse on 17 potentially overused services, such as nerve stimulators, wound care, certain surgeries and more.
Seniors on traditional Medicare and a supplement shouldn’t panic. The program will most likely eliminate some misuse, and that’s a great thing! Anything that protects the Medicare program from waste and keeps costs down for seniors should be applauded.
Your health care providers should be aware of these new requirements. If you happen to need one of the 17 services included in the program, your provider can submit the prior authorization for medical necessity. Although folks in participating states should be aware of this new process, I believe most seniors won’t even notice a difference in the usability of their coverage.
If you ever have questions concerning your Medicare coverage, I would love to help talk through them with you. Our office is in Flower Mound at 2604 Long Prairie Road Suite 100. You can always call us at 800-750-2407!
God Bless!
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