Klomp denies WISeR profit motive; docs show 25 percent

The WISeR program was rolled out in January across six states—New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington—with the goal of ensuring appropriate Medicare payment by decreasing fraud, waste, and abuse. But the implementation was rushed, and the technology was not ready. According to documents obtained by the Electronic Frontier Foundation, one vendor, Innovaccer, asked the government to delay the rollout; when it didn't, Innovaccer set up its system to automatically approve all requests temporarily. Another vendor, Zyter, had data discrepancies for months because it apparently didn't understand the difference between Medicare Part A and Part B. These technical fumbles have contributed to delays and denials that have left patients in pain and doctors frustrated. The Government Accountability Office determined in May that Trump officials did not follow proper procedure in setting up the program, calling its legality into question. Lawmakers have tried to get answers and shut the program down, but it appears to be moving ahead, with plans to expand. At the heart of the controversy is the payment model: CMS documents show contractors are paid 25 percent of the averted cost for each denial, which the CMS Office of the Actuary said gives them an incentive to deny as many claims as possible. While Klomp claimed there are penalties for inappropriate denials, the documents reveal that the penalty is small—a company with a failing quality score still gets paid 90 percent of the 25 percent. With few denials appealed, the financial incentive to deny remains strong. The stakes are high for Medicare patients and their providers, who may continue to face delays and denials unless the program is changed or stopped.