Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:01):
Welcome to Medicare three sixty, where the world of Medicare
is simplified and you are empowered to make informed healthcare choices.
With over two decades of experience and insurance and financial
solutions with host licensed insurance agents Jennifer Lee, you are
guided through the ins and outs of Medicare, whether you
(00:22):
are nearing retirement, navigating your options, or just curious about
what's available. Everything you need to know is covered. Tune
in for knowledgeable insights, tips and answers to your Medicare
questions so you can take charge of your health and
your future. And Now Medicare three sixty.
Speaker 2 (00:44):
Welcome to today's Medicare three sixty show. I'm your host,
Jennifer Lee, and let's get started today. I wanted to
cover the breakdown of the prior authorization changes coming to
original Medicare that's fe for service effective January first, twenty
twenty six under the WISER I don't know if it's
(01:08):
wise Er pilot model established by the Center of Medicare Services.
So let's begin and just keep in mind this is
for original Medicare. If you do have a Medicare advantage plan,
this has nothing to.
Speaker 3 (01:25):
Do with that.
Speaker 2 (01:26):
This is based on original Medicare if you have that
red wright and blue card if you're using that, and
also like a Medicare supplement, like a plan.
Speaker 3 (01:35):
F g RN.
Speaker 2 (01:38):
Want information on that, let us know. But today we
are going to cover first the background and the legislative
context on it.
Speaker 3 (01:47):
So part of.
Speaker 2 (01:48):
The broader reforms aiming to streamline prior author authorization across
all the payers, which is Medicaid in California. It's Medical
Cure Advantage ACA plans codified in cms's Interoperability and Prior
Authorization Final Rule January twenty twenty four. It mandates electronics
(02:13):
systems turnaround times seventy two hours, the ones that are
expedited in a seven day standard rule, denial reasons and
public reporting by twenty twenty six. So the WISER that
stands for Wasteful and Inappropriate Service Reduction Model is a
(02:36):
six state pilot targeting traditional low requirement original Medicare. It's
overseen by CMS CMMI, which can expand successful pilots without
new congressional approval. Hey, this pilot was authorized in the
(02:57):
Inflation Reduction Act. The biggest thing for that was in
twenty twenty five covered drugs were going to be capped
at two thousand.
Speaker 3 (03:07):
There was some.
Speaker 2 (03:08):
Disruption about that, so now for twenty twenty six, this
is probably the biggest disruptor of actually the six state
pilot program, so other legislative authorities aiming to test AI
assisted workflows in fee for service Medicare. So why this
is really important is because if you are an original Medicare,
(03:32):
there are no prior prior authorizations till now with the
six state pilot program, meaning if it's covered on original Medicare,
you don't need to get any approvals or authorizations like
you do in a Medicare managed plan. So this might
(03:53):
change people's options, opinions, or what plan to sway to
when getting onto Medicare. So let's talk about the pilot scope, when, where,
and what. The start date will be January first, twenty
twenty six. It will last through December thirty first, twenty
thirty one, so technically a five year pilot program. The
(04:16):
states will include New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington.
So the services targeted there are seventeen categories and examples
include Okay, electrical nerve stimulators various type, sacral phrenick deep
(04:41):
brain vegas, hypoglossal epidural steroid injections, cervical fusion, need athroscopy,
or dibridement. So I would say a lot of people,
a lot of seniors do maybe the knee stuff, just
because that's one of the things that I've seen more
(05:04):
often as ailments. Okay, Skin tissue substitutes for chronic wounds,
in continent devices, impotence treatment, spinal stinistic decompression. So I
would say, like the skin and tissue substitutes for chronic wounds.
(05:24):
I know on original Medicare it's very easy because there's
no approvals for that, so I have to seen that
and so forth. Okay, So how the prior authorization process
will work? Okay, Providers and pilot states must either request
(05:46):
pre service prior authorizations or proceed with care and later
undergo prepayment medical review. I mean I would really go
for the requests for pre service or pre authorization.
Speaker 3 (06:00):
Wants to pay something that's not going to get approved,
and since it is a pilot you need to be
careful with that and talk to your doctor.
Speaker 2 (06:09):
Technology an AI assisted system will help validate documentation and
flag requests, but licensed collisions make final decisions. I think
that's very important as AI is getting stronger and better.
Of course, I think the human brain or someone human
functioning could actually look at.
Speaker 3 (06:31):
A person situation and make sure they're having a final decision.
Speaker 2 (06:37):
So exclusions pilot does not affect affect impatient, emergency or.
Speaker 3 (06:45):
Other delayed reservices.
Speaker 2 (06:46):
Okay, that's great, because who wants to get a prior
authorization when you're in an emergency? Okay, So overarching CMS
prior authorization reforms. This is twenty twenty six and beyond
across all Medicare advantage Medicaid, which is medical in California
ACA qualified plants, including original Medicare with wiser CMS is
(07:09):
implanting the following CMS wide changes effective January first, twenty
twenty six. Okay, CMS is center Center of Medicare Services.
So I'm just saying CMS for short. I think this
is just a topic that really needs to be.
Speaker 3 (07:28):
Brought out.
Speaker 2 (07:29):
So I'm pretty much excited to give this to you.
Maybe I'm talking too fast, so let me slow down. Okay, turnaround.
Timeline seventy two hours for expedited urgent requests, seven calendar
days for non urgent requests. So my issue with this
(07:50):
is I tell my medsubclients, my Medicare original Medicare clients. Oh,
you don't have to get any authorizations or approvals necessary.
So really this is not the case. And what's going
to be outlined as something they have to be pre
authorized with.
Speaker 3 (08:07):
Those six pilot states.
Speaker 2 (08:10):
So Electronic Automated process via fhir API mandates for EPA
data exchange NILE reasons must be specific. Okay, that's good
public reporting. Health plans must publish prior authorization metrics by
March thirty.
Speaker 3 (08:28):
First, twenty twenty six.
Speaker 2 (08:31):
To me, that's a little bit funny because if it
starts on these pilots January first, twenty twenty six, that's
three months that they have time to publish the report.
What about the three months that lapsed.
Speaker 3 (08:46):
I don't know. That's healthcare for you.
Speaker 2 (08:49):
Okay, Provider access API by January first, twenty twenty seven.
Providers must access prior authorization data from payers via FHI Okay,
m IPS slash Hospital EPA measurements. Clinicians and hospitals will
report usage of EPA APIs underpromoting and operatable programs. Okay,
(09:11):
So what's the rationale, the goals and the concerns. Why
reduce waste in appropriate care by scrutinizing historical overutilized procedures.
So I get that there is a lot of fraud,
waste and abuse going on. We have to certify every
single year about that too, and report if we ever
see things like that. So I get in regards to
(09:36):
our gaps and deficit and so forth, I guess I
get the reduce waste and inappropriate care. Okay, Streamline administrative
burden through digital workflows while ensuring patient safety and evidence
based decisions. Okay, cut costs and enhance taxpayer stewardship VI
S CMMI models. Okay, So what are the concerns provider burden?
(10:01):
Some medical groups worry that even limited PA could increase
paperwork PAS the prior authorisations could increase paperwork and delay
care in original medicare.
Speaker 3 (10:12):
I mean for those providers.
Speaker 2 (10:15):
Medical groups that don't offer Medicare advantage or the HMOs
or the PPOs and only offer original Medicare, this is
going to be quite a shift for them to get
those authorizations. Hey, timely access CMS excludes emergencies, but concerns
persist regarding disruptions of course, right, sometimes client thinks center
(10:38):
this emergency, but hey, the hospital doesn't so things like that.
That is concerning reliance on AI tools. CMS clarifies that
AI assist but does not decide approvals. Okay, yes, you
know AI. It's still new while you know it's moving
in a rapid pace, so it's nice that it doesn't
(11:00):
decide their approvals. Hey, what this means for beneficials and providers.
Beneficials and pilot states receiving targeted services before January twenty
twenty six should prepare for possible delays or prior authorization steps,
Understand their process for requesting services, regain documentation, and plan
(11:24):
to appeal if denied. Providers should become familiar with AI
facilitated PA systems, submit complete clinical info to avoid denials,
track requirements, and pilot states nationwide expect faster authorizations on decisions,
transparent denial reasons, greater electronic interoperability. But of course, I
(11:49):
mean with the pilot system and all this, it is
going to really take some time to really figure out
if this is something that's great, good, or just.
Speaker 3 (12:01):
Indifferent. Right, Hey, so.
Speaker 2 (12:04):
Next steps and monitoring CMS to report pilot outcomes, costs, utilization, quality,
patient provider experience. A CMI expansion could follow. If pilot
reduces costs without harming quality. Legislative compliments. The pending Improving
Seniors Timely Access app would standardize the e prior authorizations
(12:28):
and expand prior authorization reforms, especially for Medicare advantage. So really,
this could affect Medicare advantage down the line. Definitely will
affect other states, right because if it is successful, or
however it may be, it probably will get to other states. Okay,
(12:50):
so why this matters? So for the first time, original
medicare incorporates pigher authorizations, introducing both efficiency gains and administrative
challenges to fee for service care CMS is balancing cost
control with maintaining clinical autonomy and patient access. Pilot results
(13:15):
would guide future expansion, meaning all beneficiaries and providers should
stay informed, especially.
Speaker 3 (13:22):
In pilot states.
Speaker 2 (13:25):
And if you'd like, I could explain how this impacts
specific services and walk you through state by state provider preparation,
or compare this with changes in Medicare advantage. Just let
me know, Okay, so let me.
Speaker 3 (13:44):
I still have some time.
Speaker 2 (13:47):
This is definitely a historic shift virginal medicare. As mentioned,
this is the first time that traditional Medicare will require
prior authorization and non emergency patient care. It has been
a long hot button issue in Medicare advantage, but original
Medicare was largely untouched until now because Medicare advantage mainly
(14:12):
like the HMOs and the PPOs, there are some prior
authorizations and approvals needed. So this is quite a different take,
especially when it comes to original Medicare. So for decades,
fee for service Medicare was the no hassle option. What
I used to tell my patients or my clients is, hey,
(14:34):
no approvals, no authorizations. You could go to any doctor,
any specialist hospital in the nation that expects it accepts Medicare.
You just pick up the phone and set up an appointment.
But this may not be the case because they are
about seventeen subjects that are going to need prior authorization
(14:56):
starting in twenty twenty six. And I get maybe these
are are the ones that have the highest broad Who knows,
I mean, I hope they're just targeting the services that
have the highest fraud, right or they know, because why
just burden the consumer the patient for frivolous things. Okay,
(15:22):
So remember that Arizona New Jersey, Ohio, Oklahoma, Texas, and
Washington is the sixth states. Your doctor may soon need
Medicare approval before you get certain back surgeries. Injections are
nerve stimulators. So that's the thing, right, I mean, that's
(15:43):
the biggest thing why choose a Medicare original Medicare supplemental plan.
Speaker 3 (15:49):
But now some of.
Speaker 2 (15:50):
These approvals are going to be in place, So what
kind of services are affected? The real world examples I
would say is back pain at bridural injection, spinal decompression,
so that's big. In continent devices, nerve stimulators for Parkinson's epilepsy,
(16:11):
tissue graphs for wounds. Okay, these are high cost, high
volume procedures where Medicare wants to prevent waste, but delays
could frustrate patients, especially if you're just used to not
getting any approvals.
Speaker 3 (16:26):
Okay, So the.
Speaker 2 (16:28):
Role of artificial intelligence, but with a human touch, AI
will assist with document scanning, flagging and streamlining, not making
the final decision, I hope. So licensed doctors will still
review and decide and for me, your doctor, your medical
group does make a big difference on your advocacy. Of course,
(16:48):
you need to advocate for yourself. If you can't advocate,
have your broker like us, advocate for your your family,
your friends. Just don't leave it to chance. The government
does say AI will speed things up, not takeover decisions,
but really critics are worrying it could lead to more denials. Okay,
(17:09):
timing an urgency, Like I said, it will start January first,
twenty twenty six, So I would prepare now, talk to
your doctor, check your treatment plans, and understand appeal rights.
Of course these are for the six pilot states, but
if you are getting these type of services, I do recommend,
even though you're not in the sixth pilot state, to
(17:30):
talk to your doctor see what their take on this
and so forth, and just so you kind of have
like a head start on thinking ahead and planning ahead.
So insightful angles right, what it means for the rest
of our country. CMS has authority to expand pilots nationally successful.
(17:53):
This is likely a testing ground for the broader Medicare
cost control measures, and really this might just be the
beginning the pilot cut costs without hurting care.
Speaker 3 (18:04):
Expect this to expand to all fifty states.
Speaker 2 (18:08):
Potential patient pushback. We got to watch for the growing
advocacy from patient right groups who fear treatment delays, Medicare advantages,
seems high denial rates for similar procedures, and it just
to me it really depends on the medical group, the doctor,
the level of care, even of your location, right, because
(18:31):
sometimes you're in these metropolitan cities, the care, the hospital,
the doctors are just top notch versus being in the
suburbs or in the rural areas. Things like that to
consider when looking where you want your health care, where
you want to live in retirement. So some fear this
(18:54):
will create Medicare advantage style headaches, delays, deniles, and red tapes. Yeah,
it's too soon to say, but if it's going now
down that way, it is unfortunate. Physician concerns. Many doctors
worry about added paperwork reduce autonomy and delays and care.
Some have already reduced Medicare acceptance due to administrator burden.
(19:17):
Doctors say they didn't go to bed school to fill
out forms and this can make it worse. Obviously they
should have a staff for that, right, So I'm not
sure if you are in the rural areas that they
have to fill out their medical forms. Okay, a win
for transparency. New rules force Medicare and insurance to publish
denial stats, response signs, and justification for every denial. So
(19:41):
I like that transparency that we could definitely look at
that and articulate to the clients what's going on with
the particular insurance companies we use. And so the first
time Medicare's decision will expose to public sunlight, that's a
win for patients, right, So hopefully looking at the positive here.
(20:01):
Tying it to the twenty twenty four election fallout and
the twenty twenty politics, I'm not into politics. I'm talking
about that and just a little bit of perspective as
being a healthcare broker. Healthcare reform was a major campaign issue.
This could be part of the conversation in midterms and beyond.
Speaker 3 (20:23):
So will this be seen as cutting waste or cutting care?
Speaker 2 (20:26):
That just really might depend on how smoothly it's rolled
out in twenty twenty six, and really it's based on
the individual and your perspective and your care and just
your individual needs, right and your friends and families individual
needs and what you hear out there. So it's just
different perspectives on that.
Speaker 3 (20:46):
So what should you do?
Speaker 2 (20:48):
Definitely if you're on Medicare and live in a pilot state,
talk to your doctor now, and remember prior authorizations don't
mean denials, but it does mean to possibility. Okay, we'll
be watching closely as Medicare no prior authorization era has
officially ended, well technically Gen one twenty twenty six, but
(21:15):
definitely if you are concerned and you have an individual situation,
let us know so could help guide you the process.
The biggest thing for me is client advocacy. Some seniors,
if you can't advocate for yourself or you don't even
know an understand it and understand the processes of how
(21:40):
Medicare or your healthcare works.
Speaker 3 (21:43):
That's why reach out to us.
Speaker 2 (21:45):
I've had instances lately where I usually don't have any issues,
but I had one recently where a lot of the
things a client was saying to me didn't make sense
that they couldn't find a specialist in her area, as
particular specialists. And then I said, that doesn't make sense
(22:09):
because your doctor the medical group should be able to
provide you a referral.
Speaker 3 (22:15):
And if there's no.
Speaker 2 (22:16):
One in their medical group or specialists in their group,
like they need to go elsewhere, right, and give you
that up authorization. Come to find out, she was actually
referred to a top notch specialist, a really top notch specialist. However,
(22:36):
it was really far from her so she had lived
in the suburbs, so she was looking for someone closer
and the person that she was sent to didn't take
her medical group. But I mean that's another issue for
another day. But things like that, that's why Premiere three
sixty we do advocate for clients. We do give your
(22:58):
options outside of the box. You're just not a number
to us. We definitely give you your options, escalate your
issues or your problems, you know, give you some sound
advice from what we've learned in the past or our experiences,
(23:18):
especially in your particular marketplace. So keep that in mind. So, yeah,
the biggest thing is for the first time ever, Original Medicare,
that's the government free fee for service option will begin
requiring authorizations for certain medical services. So that means doctors
will need approval before metigare agrees to pay for specific procedures. Yeah,
(23:44):
it's a lot of paperwork. I would say, it will
take more time to get your approvals right. So just
remember if you're in Texas, Oklahoma, Ohio, Washington, and New Jersey.
We are licensed in those states. Please let us know
how we could assist you. If you have any questions,
(24:06):
definitely reach out. We have been seeing changes on Medicare supplement,
larger increases this year, and it doesn't seem like it's
going to stop or decrease anytime soon. So once again,
my name is Jenni Ferley, your host at Medicare three
(24:28):
sixty sponsored by Premiere three sixty. If you have any
questions and concerns, please reach out to us. We are
more than happy to help you with your situation or
any concerns you may have. Thank you and I will see.
Speaker 3 (24:43):
You next week.
Speaker 1 (24:44):
Re Bie, thank you for joining the program Medicare three sixty.
Hope you found today's episode insightful and empowering. Remember understanding
your Medicare options is key to making the right choices
for your health and financial well being. If you have
questions or topics you would like covered in future episodes
(25:06):
of Medicare three sixty, don't hesitate to reach out and
speak with our licensed insurance agent. Until next time, stay
informed and take charge of your healthcare journey. This has
been Medicare three sixty your trusted source for all things Medicare,
take care,
Welcome to Medicare three sixty, where the world of Medicare
is simplified and you are empowered to make informed healthcare choices.
With over two decades of experience and insurance and financial
solutions with host licensed insurance agents Jennifer Lee, you are
guided through the ins and outs of Medicare, whether you
(00:22):
are nearing retirement, navigating your options, or just curious about
what's available. Everything you need to know is covered. Tune
in for knowledgeable insights, tips and answers to your Medicare
questions so you can take charge of your health and
your future. And Now Medicare three sixty.
Speaker 2 (00:44):
Welcome to today's Medicare three sixty show. I'm your host,
Jennifer Lee, and let's get started today. I wanted to
cover the breakdown of the prior authorization changes coming to
original Medicare that's fe for service effective January first, twenty
twenty six under the WISER I don't know if it's
(01:08):
wise Er pilot model established by the Center of Medicare Services.
So let's begin and just keep in mind this is
for original Medicare. If you do have a Medicare advantage plan,
this has nothing to.
Speaker 3 (01:25):
Do with that.
Speaker 2 (01:26):
This is based on original Medicare if you have that
red wright and blue card if you're using that, and
also like a Medicare supplement, like a plan.
Speaker 3 (01:35):
F g RN.
Speaker 2 (01:38):
Want information on that, let us know. But today we
are going to cover first the background and the legislative
context on it.
Speaker 3 (01:47):
So part of.
Speaker 2 (01:48):
The broader reforms aiming to streamline prior author authorization across
all the payers, which is Medicaid in California. It's Medical
Cure Advantage ACA plans codified in cms's Interoperability and Prior
Authorization Final Rule January twenty twenty four. It mandates electronics
(02:13):
systems turnaround times seventy two hours, the ones that are
expedited in a seven day standard rule, denial reasons and
public reporting by twenty twenty six. So the WISER that
stands for Wasteful and Inappropriate Service Reduction Model is a
(02:36):
six state pilot targeting traditional low requirement original Medicare. It's
overseen by CMS CMMI, which can expand successful pilots without
new congressional approval. Hey, this pilot was authorized in the
(02:57):
Inflation Reduction Act. The biggest thing for that was in
twenty twenty five covered drugs were going to be capped
at two thousand.
Speaker 3 (03:07):
There was some.
Speaker 2 (03:08):
Disruption about that, so now for twenty twenty six, this
is probably the biggest disruptor of actually the six state
pilot program, so other legislative authorities aiming to test AI
assisted workflows in fee for service Medicare. So why this
is really important is because if you are an original Medicare,
(03:32):
there are no prior prior authorizations till now with the
six state pilot program, meaning if it's covered on original Medicare,
you don't need to get any approvals or authorizations like
you do in a Medicare managed plan. So this might
(03:53):
change people's options, opinions, or what plan to sway to
when getting onto Medicare. So let's talk about the pilot scope, when, where,
and what. The start date will be January first, twenty
twenty six. It will last through December thirty first, twenty
thirty one, so technically a five year pilot program. The
(04:16):
states will include New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington.
So the services targeted there are seventeen categories and examples
include Okay, electrical nerve stimulators various type, sacral phrenick deep
(04:41):
brain vegas, hypoglossal epidural steroid injections, cervical fusion, need athroscopy,
or dibridement. So I would say a lot of people,
a lot of seniors do maybe the knee stuff, just
because that's one of the things that I've seen more
(05:04):
often as ailments. Okay, Skin tissue substitutes for chronic wounds,
in continent devices, impotence treatment, spinal stinistic decompression. So I
would say, like the skin and tissue substitutes for chronic wounds.
(05:24):
I know on original Medicare it's very easy because there's
no approvals for that, so I have to seen that
and so forth. Okay, So how the prior authorization process
will work? Okay, Providers and pilot states must either request
(05:46):
pre service prior authorizations or proceed with care and later
undergo prepayment medical review. I mean I would really go
for the requests for pre service or pre authorization.
Speaker 3 (06:00):
Wants to pay something that's not going to get approved,
and since it is a pilot you need to be
careful with that and talk to your doctor.
Speaker 2 (06:09):
Technology an AI assisted system will help validate documentation and
flag requests, but licensed collisions make final decisions. I think
that's very important as AI is getting stronger and better.
Of course, I think the human brain or someone human
functioning could actually look at.
Speaker 3 (06:31):
A person situation and make sure they're having a final decision.
Speaker 2 (06:37):
So exclusions pilot does not affect affect impatient, emergency or.
Speaker 3 (06:45):
Other delayed reservices.
Speaker 2 (06:46):
Okay, that's great, because who wants to get a prior
authorization when you're in an emergency? Okay, So overarching CMS
prior authorization reforms. This is twenty twenty six and beyond
across all Medicare advantage Medicaid, which is medical in California
ACA qualified plants, including original Medicare with wiser CMS is
(07:09):
implanting the following CMS wide changes effective January first, twenty
twenty six. Okay, CMS is center Center of Medicare Services.
So I'm just saying CMS for short. I think this
is just a topic that really needs to be.
Speaker 3 (07:28):
Brought out.
Speaker 2 (07:29):
So I'm pretty much excited to give this to you.
Maybe I'm talking too fast, so let me slow down. Okay, turnaround.
Timeline seventy two hours for expedited urgent requests, seven calendar
days for non urgent requests. So my issue with this
(07:50):
is I tell my medsubclients, my Medicare original Medicare clients. Oh,
you don't have to get any authorizations or approvals necessary.
So really this is not the case. And what's going
to be outlined as something they have to be pre
authorized with.
Speaker 3 (08:07):
Those six pilot states.
Speaker 2 (08:10):
So Electronic Automated process via fhir API mandates for EPA
data exchange NILE reasons must be specific. Okay, that's good
public reporting. Health plans must publish prior authorization metrics by
March thirty.
Speaker 3 (08:28):
First, twenty twenty six.
Speaker 2 (08:31):
To me, that's a little bit funny because if it
starts on these pilots January first, twenty twenty six, that's
three months that they have time to publish the report.
What about the three months that lapsed.
Speaker 3 (08:46):
I don't know. That's healthcare for you.
Speaker 2 (08:49):
Okay, Provider access API by January first, twenty twenty seven.
Providers must access prior authorization data from payers via FHI Okay,
m IPS slash Hospital EPA measurements. Clinicians and hospitals will
report usage of EPA APIs underpromoting and operatable programs. Okay,
(09:11):
So what's the rationale, the goals and the concerns. Why
reduce waste in appropriate care by scrutinizing historical overutilized procedures.
So I get that there is a lot of fraud,
waste and abuse going on. We have to certify every
single year about that too, and report if we ever
see things like that. So I get in regards to
(09:36):
our gaps and deficit and so forth, I guess I
get the reduce waste and inappropriate care. Okay, Streamline administrative
burden through digital workflows while ensuring patient safety and evidence
based decisions. Okay, cut costs and enhance taxpayer stewardship VI
S CMMI models. Okay, So what are the concerns provider burden?
(10:01):
Some medical groups worry that even limited PA could increase
paperwork PAS the prior authorisations could increase paperwork and delay
care in original medicare.
Speaker 3 (10:12):
I mean for those providers.
Speaker 2 (10:15):
Medical groups that don't offer Medicare advantage or the HMOs
or the PPOs and only offer original Medicare, this is
going to be quite a shift for them to get
those authorizations. Hey, timely access CMS excludes emergencies, but concerns
persist regarding disruptions of course, right, sometimes client thinks center
(10:38):
this emergency, but hey, the hospital doesn't so things like that.
That is concerning reliance on AI tools. CMS clarifies that
AI assist but does not decide approvals. Okay, yes, you
know AI. It's still new while you know it's moving
in a rapid pace, so it's nice that it doesn't
(11:00):
decide their approvals. Hey, what this means for beneficials and providers.
Beneficials and pilot states receiving targeted services before January twenty
twenty six should prepare for possible delays or prior authorization steps,
Understand their process for requesting services, regain documentation, and plan
(11:24):
to appeal if denied. Providers should become familiar with AI
facilitated PA systems, submit complete clinical info to avoid denials,
track requirements, and pilot states nationwide expect faster authorizations on decisions,
transparent denial reasons, greater electronic interoperability. But of course, I
(11:49):
mean with the pilot system and all this, it is
going to really take some time to really figure out
if this is something that's great, good, or just.
Speaker 3 (12:01):
Indifferent. Right, Hey, so.
Speaker 2 (12:04):
Next steps and monitoring CMS to report pilot outcomes, costs, utilization, quality,
patient provider experience. A CMI expansion could follow. If pilot
reduces costs without harming quality. Legislative compliments. The pending Improving
Seniors Timely Access app would standardize the e prior authorizations
(12:28):
and expand prior authorization reforms, especially for Medicare advantage. So really,
this could affect Medicare advantage down the line. Definitely will
affect other states, right because if it is successful, or
however it may be, it probably will get to other states. Okay,
(12:50):
so why this matters? So for the first time, original
medicare incorporates pigher authorizations, introducing both efficiency gains and administrative
challenges to fee for service care CMS is balancing cost
control with maintaining clinical autonomy and patient access. Pilot results
(13:15):
would guide future expansion, meaning all beneficiaries and providers should
stay informed, especially.
Speaker 3 (13:22):
In pilot states.
Speaker 2 (13:25):
And if you'd like, I could explain how this impacts
specific services and walk you through state by state provider preparation,
or compare this with changes in Medicare advantage. Just let
me know, Okay, so let me.
Speaker 3 (13:44):
I still have some time.
Speaker 2 (13:47):
This is definitely a historic shift virginal medicare. As mentioned,
this is the first time that traditional Medicare will require
prior authorization and non emergency patient care. It has been
a long hot button issue in Medicare advantage, but original
Medicare was largely untouched until now because Medicare advantage mainly
(14:12):
like the HMOs and the PPOs, there are some prior
authorizations and approvals needed. So this is quite a different take,
especially when it comes to original Medicare. So for decades,
fee for service Medicare was the no hassle option. What
I used to tell my patients or my clients is, hey,
(14:34):
no approvals, no authorizations. You could go to any doctor,
any specialist hospital in the nation that expects it accepts Medicare.
You just pick up the phone and set up an appointment.
But this may not be the case because they are
about seventeen subjects that are going to need prior authorization
(14:56):
starting in twenty twenty six. And I get maybe these
are are the ones that have the highest broad Who knows,
I mean, I hope they're just targeting the services that
have the highest fraud, right or they know, because why
just burden the consumer the patient for frivolous things. Okay,
(15:22):
So remember that Arizona New Jersey, Ohio, Oklahoma, Texas, and
Washington is the sixth states. Your doctor may soon need
Medicare approval before you get certain back surgeries. Injections are
nerve stimulators. So that's the thing, right, I mean, that's
(15:43):
the biggest thing why choose a Medicare original Medicare supplemental plan.
Speaker 3 (15:49):
But now some of.
Speaker 2 (15:50):
These approvals are going to be in place, So what
kind of services are affected? The real world examples I
would say is back pain at bridural injection, spinal decompression,
so that's big. In continent devices, nerve stimulators for Parkinson's epilepsy,
(16:11):
tissue graphs for wounds. Okay, these are high cost, high
volume procedures where Medicare wants to prevent waste, but delays
could frustrate patients, especially if you're just used to not
getting any approvals.
Speaker 3 (16:26):
Okay, So the.
Speaker 2 (16:28):
Role of artificial intelligence, but with a human touch, AI
will assist with document scanning, flagging and streamlining, not making
the final decision, I hope. So licensed doctors will still
review and decide and for me, your doctor, your medical
group does make a big difference on your advocacy. Of course,
(16:48):
you need to advocate for yourself. If you can't advocate,
have your broker like us, advocate for your your family,
your friends. Just don't leave it to chance. The government
does say AI will speed things up, not takeover decisions,
but really critics are worrying it could lead to more denials. Okay,
(17:09):
timing an urgency, Like I said, it will start January first,
twenty twenty six, So I would prepare now, talk to
your doctor, check your treatment plans, and understand appeal rights.
Of course these are for the six pilot states, but
if you are getting these type of services, I do recommend,
even though you're not in the sixth pilot state, to
(17:30):
talk to your doctor see what their take on this
and so forth, and just so you kind of have
like a head start on thinking ahead and planning ahead.
So insightful angles right, what it means for the rest
of our country. CMS has authority to expand pilots nationally successful.
(17:53):
This is likely a testing ground for the broader Medicare
cost control measures, and really this might just be the
beginning the pilot cut costs without hurting care.
Speaker 3 (18:04):
Expect this to expand to all fifty states.
Speaker 2 (18:08):
Potential patient pushback. We got to watch for the growing
advocacy from patient right groups who fear treatment delays, Medicare advantages,
seems high denial rates for similar procedures, and it just
to me it really depends on the medical group, the doctor,
the level of care, even of your location, right, because
(18:31):
sometimes you're in these metropolitan cities, the care, the hospital,
the doctors are just top notch versus being in the
suburbs or in the rural areas. Things like that to
consider when looking where you want your health care, where
you want to live in retirement. So some fear this
(18:54):
will create Medicare advantage style headaches, delays, deniles, and red tapes. Yeah,
it's too soon to say, but if it's going now
down that way, it is unfortunate. Physician concerns. Many doctors
worry about added paperwork reduce autonomy and delays and care.
Some have already reduced Medicare acceptance due to administrator burden.
(19:17):
Doctors say they didn't go to bed school to fill
out forms and this can make it worse. Obviously they
should have a staff for that, right, So I'm not
sure if you are in the rural areas that they
have to fill out their medical forms. Okay, a win
for transparency. New rules force Medicare and insurance to publish
denial stats, response signs, and justification for every denial. So
(19:41):
I like that transparency that we could definitely look at
that and articulate to the clients what's going on with
the particular insurance companies we use. And so the first
time Medicare's decision will expose to public sunlight, that's a
win for patients, right, So hopefully looking at the positive here.
(20:01):
Tying it to the twenty twenty four election fallout and
the twenty twenty politics, I'm not into politics. I'm talking
about that and just a little bit of perspective as
being a healthcare broker. Healthcare reform was a major campaign issue.
This could be part of the conversation in midterms and beyond.
Speaker 3 (20:23):
So will this be seen as cutting waste or cutting care?
Speaker 2 (20:26):
That just really might depend on how smoothly it's rolled
out in twenty twenty six, and really it's based on
the individual and your perspective and your care and just
your individual needs, right and your friends and families individual
needs and what you hear out there. So it's just
different perspectives on that.
Speaker 3 (20:46):
So what should you do?
Speaker 2 (20:48):
Definitely if you're on Medicare and live in a pilot state,
talk to your doctor now, and remember prior authorizations don't
mean denials, but it does mean to possibility. Okay, we'll
be watching closely as Medicare no prior authorization era has
officially ended, well technically Gen one twenty twenty six, but
(21:15):
definitely if you are concerned and you have an individual situation,
let us know so could help guide you the process.
The biggest thing for me is client advocacy. Some seniors,
if you can't advocate for yourself or you don't even
know an understand it and understand the processes of how
(21:40):
Medicare or your healthcare works.
Speaker 3 (21:43):
That's why reach out to us.
Speaker 2 (21:45):
I've had instances lately where I usually don't have any issues,
but I had one recently where a lot of the
things a client was saying to me didn't make sense
that they couldn't find a specialist in her area, as
particular specialists. And then I said, that doesn't make sense
(22:09):
because your doctor the medical group should be able to
provide you a referral.
Speaker 3 (22:15):
And if there's no.
Speaker 2 (22:16):
One in their medical group or specialists in their group,
like they need to go elsewhere, right, and give you
that up authorization. Come to find out, she was actually
referred to a top notch specialist, a really top notch specialist. However,
(22:36):
it was really far from her so she had lived
in the suburbs, so she was looking for someone closer
and the person that she was sent to didn't take
her medical group. But I mean that's another issue for
another day. But things like that, that's why Premiere three
sixty we do advocate for clients. We do give your
(22:58):
options outside of the box. You're just not a number
to us. We definitely give you your options, escalate your
issues or your problems, you know, give you some sound
advice from what we've learned in the past or our experiences,
(23:18):
especially in your particular marketplace. So keep that in mind. So, yeah,
the biggest thing is for the first time ever, Original Medicare,
that's the government free fee for service option will begin
requiring authorizations for certain medical services. So that means doctors
will need approval before metigare agrees to pay for specific procedures. Yeah,
(23:44):
it's a lot of paperwork. I would say, it will
take more time to get your approvals right. So just
remember if you're in Texas, Oklahoma, Ohio, Washington, and New Jersey.
We are licensed in those states. Please let us know
how we could assist you. If you have any questions,
(24:06):
definitely reach out. We have been seeing changes on Medicare supplement,
larger increases this year, and it doesn't seem like it's
going to stop or decrease anytime soon. So once again,
my name is Jenni Ferley, your host at Medicare three
(24:28):
sixty sponsored by Premiere three sixty. If you have any
questions and concerns, please reach out to us. We are
more than happy to help you with your situation or
any concerns you may have. Thank you and I will see.
Speaker 3 (24:43):
You next week.
Speaker 1 (24:44):
Re Bie, thank you for joining the program Medicare three sixty.
Hope you found today's episode insightful and empowering. Remember understanding
your Medicare options is key to making the right choices
for your health and financial well being. If you have
questions or topics you would like covered in future episodes
(25:06):
of Medicare three sixty, don't hesitate to reach out and
speak with our licensed insurance agent. Until next time, stay
informed and take charge of your healthcare journey. This has
been Medicare three sixty your trusted source for all things Medicare,
take care,
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