New Restrictions On Some Treatments Coming For NJ Medicare Patients

New Jersey patients who use Medicare should expect new requirements for prior authorizations for more than a dozen services beginning Jan. 1, under a new process for providers that is set to roll out.

The new process is supposed to target waste, fraud and abuse in Medicare, according to the federal Centers for Medicare and Medicaid Services. It is set to roll out in New Jersey and five other states.

Inpatient-only services, emergency services, and services that would pose a substantial risk to patients if significantly delayed are excluded from the prior authorization process, federal officials said.

Health care providers will be paid based on a share of averted expenditures — requests that did not result in a paid claim — rather than on a fixed fee or per-claim basis, according to detailed information about the program.

Federal officials said the program will not change Medicare coverage or payment criteria and the program does not apply to Medicare Advantage.

Among the medical services and items targeted for prior authorization are skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy for knee osteoarthritis, federal officials said, "items and services that have been identified as particularly vulnerable to fraud, waste, and abuse, or inappropriate use." (See the list below.)

The prior authorization reviews will be conducted using artificial intelligence, but federal officials said final decisions denying authorization "will be made by licensed clinicians, not machines," officials said.

Under the model, health care providers and medical suppliers will have the choice of submitting claims for prior authorization, or their claims will be subject to medical reviews before Medicare pays the claim.

"Health care coverage for Original Medicare beneficiaries remains the same, and beneficiaries retain the freedom to seek care from their provider or supplier of choice," according to federal officials.

The program is called the WISeR Model, which stands for Wasteful and Inappropriate Service Reduction. It will be run through a partnership between the Center for Medicare and Medicaid Services and companies specializing in enhanced technologies, "helping patients and providers avoid unnecessary or inappropriate care and safeguarding federal taxpayer dollars," federal officials said.

"Low-value services, such as those of focus in WISeR, offer patients minimal benefit and, in some cases, can result in physical harm and psychological stress," said Abe Sutton, director of the Center for Medicare and Medicaid Services Innovation Center.

Companies that demonstrate "strong compliance records" may eventually qualify for exemptions from WISeR review, federal officials said.

There also will be adjustments in payment for health care providers "based on their performance against established quality and process measures that measure the model participants’ ability to support faster decision-making for providers and suppliers and improve provider, supplier and beneficiary experience with the prior authorization process," federal officials said.

In addition to New Jersey, the prior authorization program is being set to be tested in Arizona, Washington, Oklahoma, Texas and Ohio.

Here is a list of services that will require prior authorizations beginning Jan. 1, under the program:

• Electrical Nerve Stimulators
• Sacral Nerve Stimulation for Urinary Incontinence
• Phrenic Nerve Stimulator
• Deep Brain Stimulation for Essential Tremor and Parkinson’s Disease
• Vagus Nerve Stimulation
• Induced Lesions of Nerve Tracts
• Epidural Steroid Injections for Pain Management
• Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF)
• Cervical Fusion (Excluding codes already included in OPD)
• Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee
• Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea
• Incontinence Control Devices
• Diagnosis and Treatment of Impotence
• Percutaneous Image-Guided Lumbar Decompression for Spinal Stenosis
• Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds
• Wound Application of Cellular and/or Tissue Based Products (CTPs), Lower Extremities