__________
Article "Medicare Will Require Prior Approval for Certain Procedures" - NYT, 2025-08-28, has no reference to Medicare "rationing" services, and for good reason - neither "traditional" Medicare (even with Medigap) nor Medicare Advantage, which already enrolls more than half of Medicare recipients and becoming more popular, ever provided all-you-can-eat services. **
Article also acknowledged that: "... There are clear-cut examples where Medicare has wasted billions on questionable medical care. The agency came under scrutiny earlier this year for spending billions of dollars on expensive "skin substitutes" of dubious value. ... A.I. screening tool would focus narrowly on about a dozen procedures, which it has determined to be costly and of little to no benefit to patients."
"Prior approval" may prevent costly, unnecessary procedures and a lot of Medicare fraud, which is a well-known issue that cost CMS and law enforcement billions.
AI is being thrown right and left (see "AI Startup Once Worth $1.5 Billion Now Worthless" - drudge.com), but you could write these "screening tools" in COBOL, if you had to - most of them just compare the procedure request with the patient's plan tables of allowed/disallowed - whitelist/blacklist codes.
The "use of 'AI' for prior approval" resulting in high(er) rate of denials by UHC, Cigna and Humana was much discussed last year - the reason is that most were allowed after appeal when request was corrected and properly re-filed (e.g., often by providers/doctors not familiar with particular plan), which was in ~82% of the cases.
This research has a lot of data and charts:
www.kff.org - Medicare Advantage Insurers Made Nearly 50 Million Prior Authorization Determinations in 2023 - KFF, 2025-01-28
|------- Prior authorization requirements are intended to ensure that health care services are medically necessary by requiring approval before a service or other benefit will be covered. Medicare Advantage insurers typically use prior authorization, along with other tools, such as provider networks, to manage utilization and lower costs...
This analysis uses data submitted by Medicare Advantage insurers to the Centers for Medicare and Medicaid Services (CMS) to examine the trends in the number of requests for prior authorization determinations, denials, and appeals for 2019 through 2023, as well as differences across Medicare Advantage insurers.-------|
US Healthcare insurance companies directly employ less than 900,000 people (not counting free-lancers/brokers) and are currently managing about 54% of Medicare, their average net profit margin is ~1.4% (outside of AARP's fav UnitedHealth which owns PBM, at ~3.5-5.0%) - exactly the reason government outsources some Medicare, VA and other healthcare services to them to increase efficiency and reduce costs, which includes limited plans that deny "unnecessary" - IOW, "unapproved" or not pre-approved proocedures - thus making THEM "bad guys," not the government.
__________
