Medicare WISeR Program Faces Delays, Data Problems, and High Rejection Rates

Documents released by the Electronic Frontier Foundation (EFF) show that the Medicare WISeR program was rushed into operation before its technology was ready. The program requires prior approval for about a dozen medical services, including nerve stimulation, epidural steroid injections for pain, cervical fusion, skin substitutes for wounds, and treatments for incontinence and impotence.

Several vendors involved in the program encountered technical and operational problems. Innovaccer was reportedly so unprepared that it asked the government to delay the rollout. When the launch was not delayed, the company created a temporary system that automatically approved all requests.

“Innovaccer is the only available method to avoid creating a backlog of outstanding pre-approvals and claims while finalizing, validating and deploying a complete rules-based solution,” the company wrote in a letter to government officials.

Vendors faced Medicare billing and data problems

Other vendors continued operating despite apparent issues. Zyter reportedly failed to distinguish between Medicare Part A, which covers inpatient care, and Part B, which covers outpatient services. The error resulted in months of data discrepancies.

Zyter CEO Sundar Subramanian told Ars Technica in a written statement that the company is now “fully operational with Medicare Part A and Part B billing.” Subramanian said Zyter is working closely with federal partners and health care providers to “enhance the experience.”

More Medicare prior-authorization requests were rejected than approved

Another vendor, Virtix, was found to be rejecting more pre-authorization requests than it was approving. According to its March 30 weekly report, Virtix investigated 6,096 pre-authorization requests. It approved 2,863 and rejected 3,233, or 53 percent.

Some approval decisions took weeks or months

In addition to the high number of rejections, decisions from various contracting companies often took longer than expected. WISeR aims to make approval decisions within 72 hours, but some requests took weeks or even months.

Documents released by the EFF show that at least one request remained pending after 83 days. One health care provider involved in the study said, “My surgery was postponed for almost two months because there was zero communication.”