So far, the program requires prior authorization for about a dozen medical services, including nerve stimulation, epidural steroid injections for pain, cervical fusions (which permanently connect the bones in the neck), skin substitutes for wounds, and treatments for incontinence and impotence.
According to documents released by the EFF, the implementation of the program was rushed and the technology was not ready. One vendor, Innovaccer, was so unprepared that it asked the government to delay the launch, and when it didn’t, the vendor set its program to automatically approve all applications temporarily.
“[A]Self-affirmation is the only path available that avoids creating a backlog of unprocessed prior authorizations and claims while we finalize, validate, and implement the entire rules-based solution,” Innovaccer wrote, according to a letter it sent to government officials.
But others continued. One provider, Zyter, had data discrepancies for months because it apparently didn’t understand the difference between Medicare Part A, which covers hospital and inpatient care, and Part B, which covers outpatient services. Zyter CEO Sundar Subramanian told Ars Technica in a written statement that the company is now “fully functional across all Medicare Parts A and B claims.” The company is working closely with federal partners and healthcare providers to “improve the experience,” Subramanian said.
More denials than approvals
Another vendor, Virtix, was found to be denying more prior authorization requests than it was approving. According to a weekly report on March 30, Virtix had reviewed 6,096 prior authorization requests. He approved 2,863 of them and denied 3,233 (53 percent).
In addition to a questionable number of denials, decisions by the various contracted companies often took too long. WISeR is intended to provide authorization decisions within 72 hours, but many have taken weeks, some even months. EFF documents reveal that at least one application was still pending after 83 days. In one survey, one healthcare provider said “a surgery was delayed almost two months due to lack of communication.”
