Part 2 of 2: The private equity profits, contingency-fee incentives, and AI gatekeeping at the heart of the shadow system reviewing your Medicare claims.
Important work and I hope it reaches more clinicians before WISeR expands.
A footnote from the pharmacy benefits side worth adding for providers, because it gives them context that WISeR is not novel architecture. It is Medicare importing a model fully deployed in commercial pharmacy benefits for years. AI-driven prior authorization vendors operating under contingency or shared-savings economics have been standard in the PBM-administered pharmacy channel since roughly 2018. The transparency gap you describe, where providers receive the nonaffirmation but not the algorithmic reasoning, is the same gap commercial providers have been navigating in pharmacy for most of that time. CMS is borrowing an operating model, not inventing one.
Your Lewin Group note deserves more weight than it received. The same parent that owns Lewin also owns OptumRx (one of three PBMs processing roughly 80% of U.S. prescriptions), multiple specialty pharmacies, and a large physician employment footprint. When a single corporate family owns the contractor measuring Medicare payment error rates, a PBM administering commercial pharmacy benefits, a specialty pharmacy dispensing the drugs, and the physicians prescribing them, the accountability gap is not a provider-facing problem alone. It is structural across the entire payment and care delivery stack.
Thank you for the outstanding comment and reply. I made the connection with PBMs but I didn’t want to conflugate the issues between Medical claims and Pharmacy Claims.
But yes, they are just borrowing the PBM system and applying it to CMS claims processing.
Its a way to break healthcare without exposing that you are breaking healthcare.
Next stop: How to Break Hospitals - Coming soon by a Trump-backed Capital investment group near you.
I fail to understand the obsession with possible fraud in Healthcare, or any service. The cost of reviewing and re-reviewing cannot possibly be justified in returns. The money would be better spent on providing adequate Healthcare. (I am Canadian, with imperfect but significantly more equitable Healthcare.)
So, it sounds like we've also identified where SkyNet is going to be born - somewhere in Palantir's data farms
Thank you from a patient point of view! No wonder US healthcare is so out of touch & expensive 😞
Important work and I hope it reaches more clinicians before WISeR expands.
A footnote from the pharmacy benefits side worth adding for providers, because it gives them context that WISeR is not novel architecture. It is Medicare importing a model fully deployed in commercial pharmacy benefits for years. AI-driven prior authorization vendors operating under contingency or shared-savings economics have been standard in the PBM-administered pharmacy channel since roughly 2018. The transparency gap you describe, where providers receive the nonaffirmation but not the algorithmic reasoning, is the same gap commercial providers have been navigating in pharmacy for most of that time. CMS is borrowing an operating model, not inventing one.
Your Lewin Group note deserves more weight than it received. The same parent that owns Lewin also owns OptumRx (one of three PBMs processing roughly 80% of U.S. prescriptions), multiple specialty pharmacies, and a large physician employment footprint. When a single corporate family owns the contractor measuring Medicare payment error rates, a PBM administering commercial pharmacy benefits, a specialty pharmacy dispensing the drugs, and the physicians prescribing them, the accountability gap is not a provider-facing problem alone. It is structural across the entire payment and care delivery stack.
Restacking.
Thank you for the outstanding comment and reply. I made the connection with PBMs but I didn’t want to conflugate the issues between Medical claims and Pharmacy Claims.
But yes, they are just borrowing the PBM system and applying it to CMS claims processing.
Its a way to break healthcare without exposing that you are breaking healthcare.
Next stop: How to Break Hospitals - Coming soon by a Trump-backed Capital investment group near you.
I fail to understand the obsession with possible fraud in Healthcare, or any service. The cost of reviewing and re-reviewing cannot possibly be justified in returns. The money would be better spent on providing adequate Healthcare. (I am Canadian, with imperfect but significantly more equitable Healthcare.)