So far, the program requires prior authorization for around a dozen medical services, including nerve stimulation, epidural steroid injections for pain, cervical fusions (permanently connecting bones in the neck), skin substitutes for wounds, and treatments for incontinence and impotence.
According to the documents released by the EFF, the program’s implementation was rushed, and the technology wasn’t ready. One vendor, Innovaccer, was so unprepared that it asked the government to delay the rollout, and when it didn’t, the vendor set up its program to automatically approve all requests temporarily.
“[A]uto-affirming is the only path available that avoids creating a backlog of unprocessed prior authorizations and claims while we finalize, validate, and deploy the full rules-based solution,” Innovaccer wrote, according to a letter it sent to government officials.
But others carried on. One vendor, Zyter, had data discrepancies for months because it apparently didn’t understand the difference between Medicare Part A, which covers inpatient/hospital care, and Part B, which covers outpatient services. Zyter’s CEO, Sundar Subramanian, told Ars Technica in a written statement that the company is now “fully functional across Medicare Part A and Part B claims.” The company is working closely with federal partners and the healthcare providers to “enhance 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 pre-authorization requests. It approved 2,863 of them, denying 3,233 (53 percent).
In addition to a questionable number of denials, decisions from 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. The documents from EFF reveal at least one request was still pending after 83 days. In a survey, one healthcare provider said it “had a surgery pushed back almost two months due to zero communication.”