Washington State Chosen for WISeR Medicare Waste/Fraud Pilot

In late June, the Centers for Medicaid and Medicare Innovation released plans to include Washington State in a six-state, six-year pilot project, aimed at curbing Medicare spending and incidents of fraud.  The other states include  New Jersey, Oklahoma, Ohio, Texas, and Arizona. 

Known as the Wasteful and Inappropriate Service Reduction (WISeR) program, the WISeR pilot will expand pre-authorization requirements to traditional Medicare, which is currently limited to very few provider-recommended procedures.  This pre-authorization model is commonplace with privatized Medicare Advantage plans that have well-documented high denial rates for medically necessary procedures.

The pilot conflicts with two long-standing federal healthcare priorities of RPEC – to ensure public sector retirees have access to quality healthcare and to preserve and expand access to traditional Medicare.  This pilot will hamper the ability for Medicare beneficiaries to receive timely, necessary care.  And, the parameters of the pilot undermine a foundational tenant of Medicare – which places decision-making about healthcare matters with the patient and the healthcare provider, not a third party.

In addition to relegating important and medically necessary healthcare decisions to a third party (contractors with private insurance companies and Medicare Advantage plans), the pilot will also use artificial intelligence (AI) chatbots to screen and determine the necessity for the medical procedures. The third-party contractors will be compensated based on a share of the “averted expenditures,” meaning that they will be paid more for denying claims.

In mid-October, President Clair Olivers, Treasurer Jeff Paulsen and Executive Director Laurie Weidner will be meeting with Congressional healthcare staff in Washington D.C. to communicate RPEC’s concerns and to request their support for terminating the pilot.  They will also be sharing concerns about the cuts made to Medicare, Medicaid and Social Security and efforts to privatize these successful programs. Updates about the pilot will be provided through the weekly NewsFlash and the Legislative Update Calls slated for November 7^th and December 5^th.