Salta al contenuto principale

mastodon - Collegamento all'originale

Traditional #Medicare to use AI to approve or deny coverage pre-approval of medical procedures, AI companies will be paid based on denials...The AI firms have an incentive to say "no" to coverage because of the direct payments they make for each denial. Some procedures should mostly be AI processed only. #USPol

kcra.com/article/medicare-pilo…

:pdf: Extremely short AI company application packet from CMS with overview and concepts.
cms.gov/files/document/wiser-m…

8. Payment Design Payment Design Payments to WISeR model participants wil be based on the demonstrated reductions in spending for medically unnecessary or non-covered services, as defined by the Original Medicare LCD or NCD. For each of the selected items and services, a participant will receive a percentage of the reduction in expenditures, or savings, that can be directly attributed to the prior authorization review process in their applicable region. These savings will be calculated from requests that did not result in a paid claim (i., non-affirmations not followed by an affirmed resubmission or a successfully appealed claim denial), multiplied by the average claim- level payments for historical regional claims submitted with the applicable item(s)/servicels) ‘during the prior 12 months (adjusted for performance year pricing). The use of total claim payments in the savings calculation (as opposed to claim-line payments for the eligible CPT*/HCPCS codes) is intended to accurately depict the total revenue impact, including secondary or add-on services that are regularly billed and reimbursed along with the primary procedure or service codes.
#USPol #Medicare
⇧