WISER denials

[giddyup]

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I’m in Ohio, and we are now getting a massive number of WISER denials. I’ve heard they have outsourced their authorization process to various companies, and I’m suddenly seeing a significant increase in denials.

Some of the reasons have been that the patient has an “excluded diagnosis,” such as fibromyalgia, even though previous epidural provided 75% relief for six months. Another patient had a remote history of CRPS, but his brand-new MRI showed severe right foraminal stenosis at L3. They denied his transforaminal epidural because of the prior CRPS diagnosis.

They are also denying procedures if the patient is not actively participating in formal physical therapy at that exact time. Even a physician-guided home exercise program is apparently not sufficient. They want patients actively enrolled in PT, which is completely unrealistic for patients receiving repeat treatments—they cannot remain in formal PT indefinitely.

I’m going to start taking screenshots of these denials and posting them here. I feel like I read somewhere that they may be doing away with the WISER program. Has anyone else heard anything about this?

 

[IYKYK]

They are actively trying to get rid of it, but for now its still active.

Nelson Mullins - Is the WISeR Prior Authorization Pilot Dead or Alive?

The House Appropriations Committee voted to effectively defund the Wasteful and Inappropriate Service Reduction (WISeR) prior authorization pilot, a program that has faced bipartisan scrutiny since its rollout earlier this year. An amendment adopted by voice vote on June 9 would bar the Centers...

www.nelsonmullins.com

 

[mille125]

That sounds weird to me and I have never seen a WISER denial for the PT reason you list. There is nothing in the LCD that I know of that says that they have to be actively enrolled in PT. They had to fail conservative therapy but their exercise regimen can be home exercises.

I would suggest that you only put diagnosis on the days visit that pertain to the radiculopathy problem. I never list fibromyalgia on a day that I am evaluating for an epidural injection.

Feel free to post your denials as you said. I think something else may be going on.

 

[giddyup]

 

[giddyup]

 

[SSdoc33]

View attachment 422201

yes, the patient is actively participating in a rehabilitation program. EVERYONE is. a "rehabilitation" program can be just about aything

those bastards

the more i do this, the more i want to stick it to them

 

[giddyup]

this was in both of their office notes: Patient now currently does physician managed home exercise and stretching and rehab program at least 2-3 times per week

 

[DODOCSS]

this was in both of their office notes: Patient now currently does physician managed home exercise and stretching and rehab program at least 2-3 times per week

best response to AI is... AI

 

[Agast]

View attachment 422201

They need to re-read LCD 39015 then, because it directly says home exercise is fine

LCD - Epidural Steroid Injections for Pain Management (L39015)

Use this page to view details for the Local Coverage Determination for Epidural Steroid Injections for Pain Management.

www.cms.gov

"Conservative Therapy – Consists of an appropriate combination of medication (for example, non-steroidal anti-inflammatory [NSAIDs], analgesics, etc.) in addition to physical therapy, spinal manipulation therapy, cognitive behavioral therapy (CBT), home exercise program, or other interventions based on the individual’s specific presentation, physical findings, and imaging results."

 

[Agast]

BTW, part of the rationale for home-based exercises guided by your physician is not everyone has access to PT. If you live out in the middle of nowhere there is not going to be PT.

 

[mille125]

Wow...that is insane and outside of the LCD. Problem is there is no peer to peer and no person you can speak to. It's all AI.

Which company does your WISER? Ours is Cohere. Maybe best action is to reach out to that company. Their AI algorithm is wrong as they are supposed to follow LCD.

Consider contacting your Congressman and definitely your state pain society and ASIPP.

Who is your Congressman? I will send a letter too. I have an Ohio license.

 

[Laryngospasm]

BTW, part of the rationale for home-based exercises guided by your physician is not everyone has access to PT. If you live out in the middle of nowhere there is not going to be PT.

Yes and also many patients can’t afford the pt their insurance refuses to cover or the copays at every visit. This is a huge expense to many people.

 

[mille125]

Yes and also many patients can’t afford the pt their insurance refuses to cover or the copays at every visit. This is a huge expense to many people.

They are not allowed to deny on something that is clearly allowed in the LCD.

It may not be intentional but it is unlawful.

 

[mille125]

Your contractor appears to be Innovaccer.

I would try to reach their medical director

 

[GoBeers]

Wow...that is insane and outside of the LCD. Problem is there is no peer to peer and no person you can speak to. It's all AI.

Which company does your WISER? Ours is Cohere. Maybe best action is to reach out to that company. Their AI algorithm is wrong as they are supposed to follow LCD.

Consider contacting your Congressman and definitely your state pain society and ASIPP.

Who is your Congressman? I will send a letter too. I have an Ohio license.

ahh... gone are the days of just contacting the insurance company and requesting peer 2 peer with a non-qualified physician.

Now we have to contact 1) congressman, 2) state pain society, and 3) ASIPP to get things covered.

 

[mille125]

ahh... gone are the days of just contacting the insurance company and requesting peer 2 peer with a non-qualified physician.

Now we have to contact 1) congressman, 2) state pain society, and 3) ASIPP to get things covered.

No people....its all AI

 

[Agast]

No people....its all AI

In my clinic we call him Al, like Al Green….goddammit Al is hallucinating again, pull it together Al.

 

[SpineandWine]

I’m in ohio too. Other ridiculous reasons for denials
- MRI is not within last year - they want a new MRI every year?
- not actively participating in PT as you mentioned
- did not mention that I plan to only do four in calendar year for the first one I booked

I am tempted to make patient do video visit for denials and discuss reason for it and resubmit. I can’t get myself to do it because I feel bad for the patient. If they keep doing this, I may do it.

 

[giddyup]

I’m in ohio too. Other ridiculous reasons for denials
- MRI is not within last year - they want a new MRI every year?
- not actively participating in PT as you mentioned
- did not mention that I plan to only do four in calendar year for the first one I booked

I am tempted to make patient do video visit for denials and discuss reason for it and resubmit. I can’t get myself to do it because I feel bad for the patient. If they keep doing this, I may do it.

This is what I have been doing and it’s working well, we resubmit and it’s quickly approved. I also tell them to file a complaint with the Ohio department of insurance.

 

[mille125]

Does the ODI have any power over federal plans?

 

[giddyup]

Does the ODI have any power over federal plans?

great question, haven't looked into that. probably should make sure they aren't wasting their time

 

[mille125]

great question, haven't looked into that. probably should make sure they aren't wasting their time

I dont believe they do. They only have jurisdiction on commercial and worker's comp plans.

I would definitely check before you put any time into it.

 

[sloh]

They don't care about LCD's. Once a claim makes it past PA and the service gets delivered, it hits the payer’s claims platform, which runs the line items through an edit engine. The edit engine applies tens of thousands of rules drawn from CMS NCCI, MUEs, AMA CPT guidance, specialty society policy, payer-specific rules, and the vendor’s own proprietary editing logic. Each edit either pays, partially pays, or auto-denies. Most denials never see a human eye on the payer side until a provider appeals.

The thing to internalize is that these are not neutral utilities. Each vendor has its own editing library, its own AI overlay, its own customer-specific rule packs, and its own opinions about how aggressive to be on edges. Plans buy not just software but a posture. “We license Lyric for pre-pay and CES for post-pay and Zelis for OON” is a coherent statement about how a plan wants to behave in the market, and the resulting denial pattern is the consequence.

A meaningful share of the claim editing and payment integrity market is paid on contingency. The vendor takes a cut of the “savings” it identifies, where savings means dollars the payer didn’t have to pay the provider. Quoted contingency rates vary, but a 15 to 30 percent take is a normal industry range, sometimes higher for difficult finds, sometimes lower for high-volume edits. Read that economic structure out loud. The vendor is paid more when the vendor denies more. The vendor’s product roadmap is shaped by the dollars the vendor can identify. The vendor’s sales pitch to the payer is literally “we found X million dollars of savings for a comparable plan, want the same.” If a payer asks the vendor to dial down aggressiveness because providers are screaming, the vendor’s revenue takes a direct hit. The plan’s medical director may want to be reasonable about borderline edits. The vendor’s CRO has a quota.

 

[buddababa]

y'all see the new proposed rules? no same day injections otherwise consequences etc. maybe doing anesthesia will be more simpler

 

[SpineandWine]

y'all see the new proposed rules? no same day injections otherwise consequences etc. maybe doing anesthesia will be more simpler

No, what proposed rules?
Does this include knee injections in clinic?

 

[buddababa]

No, what proposed rules?
Does this include knee injections in clinic?

For CY 2027, we are proposing to reduce payment when a separately identifiable office/outpatient evaluation and management (E/M) visit is furnished by the same physician (or a physician in the same practice) on the same day as a 0-, 10-, or 90-day global procedure. The most expensive service (either surgical or E/M visit) would be paid at 100% and all other surgical procedure(s) or E/M visit(s) furnished on the same day would be paid at 50%.

 

[SSdoc33]

For CY 2027, we are proposing to reduce payment when a separately identifiable office/outpatient evaluation and management (E/M) visit is furnished by the same physician (or a physician in the same practice) on the same day as a 0-, 10-, or 90-day global procedure. The most expensive service (either surgical or E/M visit) would be paid at 100% and all other surgical procedure(s) or E/M visit(s) furnished on the same day would be paid at 50%.

need the full link

we dont have globals for our procedures. that is typically for surgeries, no? i think this applies to post-ops

 

[SpineandWine]

I never do E&M and procedure on same day with exception of in office knee and TPI injections. Guess I’ll have to book those seperately

 

[Ducttape]

i thought that is what they do already for add on code -25.

 

[DODOCSS]

need the full link

we dont have globals for our procedures. that is typically for surgeries, no? i think this applies to post-ops

RFAs do

 

[SSdoc33]

RFAs do

That’s news to me. Link?

 

[mille125]

need the full link

we dont have globals for our procedures. that is typically for surgeries, no? i think this applies to post-ops

Stims have a global but it is short.

 

[mille125]

RFAs do

Never heard of RFAs having a global. How many days is it?

 

[mille125]

For CY 2027, we are proposing to reduce payment when a separately identifiable office/outpatient evaluation and management (E/M) visit is furnished by the same physician (or a physician in the same practice) on the same day as a 0-, 10-, or 90-day global procedure. The most expensive service (either surgical or E/M visit) would be paid at 100% and all other surgical procedure(s) or E/M visit(s) furnished on the same day would be paid at 50%.

If you read what this says, the proposal is reducing the lowest paying procedure (usually E/M) for all instances. His text says global or 0, 10, or 90. Global of zero means all times.

 

[mille125]

If you read what this says, the proposal is reducing the lowest paying procedure (usually E/M) for all instances. His text says global or 0, 10, or 90. Global of zero means all times.

For me that is easy. They can schedule another day. Not taking 50% hit on an office visit that is already discounted.

 

[Agast]

You know what’s hilarious. The ASCs independently need to get WISeR approval for procedures as well, but since I’m “gold status” when they go to load my cases into the portal they get an error message. They can’t actually get approval for anything I’m doing, and the person they called wasn’t sure what that meant for them.

So they just have to wait and see if they get paid…

 

[mille125]

You know what’s hilarious. The ASCs independently need to get WISeR approval for procedures as well, but since I’m “gold status” when they go to load my cases into the portal they get an error message. They can’t actually get approval for anything I’m doing, and the person they called wasn’t sure what that meant for them.

So they just have to wait and see if they get paid…

They should just like pre Wiser

 

[DOctorJay]

That’s news to me. Link?

10 days for RFA

https://fastrvu.com/cpt/64635

 

[nvrsumr]

I read this was aimed at derm.

 

[mille125]

New issue and question for those of you in WISER area with exempt gold cards starting 7/6/26

Sat down with my biller. We have a bunch of claims on ESIs done after 7/6/26 which Medicare is denying them for payment with a CO-284 code which means that their was not prior authorization.

When my biller called, he is being told that yes the provider has an exemption but the group does not. This makes no sense as a group cannot get a gold card, it is only individuals. He is now being told to discuss with the WISER claims department but he is going in circles. For those of you that have WISER gold cards, are you seeing this issue? Have you been paid on any claims since 7/6 for epidurals?

 

[Agast]

I’m sorry what?

Doing an epidural is not a group project.

I’ll check with my biller

 

[SpineandWine]

Must be nice! I keep getting denials and don’t have gold status. They’re denying me for semantics.

Can you guys share your wiser dot phrases (those in gold status)- or tips. Please PM if you feel uncomfortable for forum

 

[NVO]

Today the ASC told me they have gold status as a facility but they're not sure if I have gold status. I have no clue how any of this works.

 

[clubdeac]

New issue and question for those of you in WISER area with exempt gold cards starting 7/6/26

Sat down with my biller. We have a bunch of claims on ESIs done after 7/6/26 which Medicare is denying them for payment with a CO-284 code which means that their was not prior authorization.

When my biller called, he is being told that yes the provider has an exemption but the group does not. This makes no sense as a group cannot get a gold card, it is only individuals. He is now being told to discuss with the WISER claims department but he is going in circles. For those of you that have WISER gold cards, are you seeing this issue? Have you been paid on any claims since 7/6 for epidurals?

I’m sure they’re probably going after you because from what you’ve shared your a very high utilizer and outlier. Over utilization is a big thing with them and I’m sure you have a bulls eye on your back. Make sure you’re doing things for the right indications and are spending an appropriate amount of time working patients up. That should help

 

[SpineandWine]

I’m sure they’re probably going after you because from what you’ve shared your a very high utilizer and outlier. Over utilization is a big thing with them and I’m sure you have a bulls eye on your back. Make sure you’re doing things for the right indications and are spending an appropriate amount of time working patients up. That should help

I doubt that’s the reason.
WISER sucks. They’re denying things for saying I didn’t state I won’t use X-ray or I only plan to do 4 in calendar year.
I’m helping AI to look at all lcd, ncd etc

 

[sloh]

I’m sure they’re probably going after you because from what you’ve shared your a very high utilizer and outlier. Over utilization is a big thing with them and I’m sure you have a bulls eye on your back. Make sure you’re doing things for the right indications and are spending an appropriate amount of time working patients up. That should help

Yep, these insurers play dirty. Even Medicare contracts out to third-party vendors, and they will find any way to deny claims because they are paid on contingency. And I mean, in any way. It's a bit of a David and Goliath, but we can't win versus Goliath. When you're a significant outlier and they have a strong desire to claw back money, they will find a way.

 

[SpineandWine]

Yep, these insurers play dirty. Even Medicare contracts out to third-party vendors, and they will find any way to deny claims because they are paid on contingency. And I mean, in any way. It's a bit of a David and Goliath, but we can't win versus Goliath. When you're a significant outlier and they have a strong desire to claw back money, they will find a way.

I do TONS of ESIs. Definitely outlier but that’s my entire market as I work only with spine surgeons

I barely do neuromodulation

 

[mille125]

I’m sorry what?

Doing an epidural is not a group project.

I’ll check with my biller

Thanks....my authorizations person was putting something in the claims that was getting it rejected. Biller figured it out. Whew......

Easy fix.

 

[mille125]

I’m sure they’re probably going after you because from what you’ve shared your a very high utilizer and outlier. Over utilization is a big thing with them and I’m sure you have a bulls eye on your back. Make sure you’re doing things for the right indications and are spending an appropriate amount of time working patients up. That should help

Thanks...that actually never crossed my mind. You can assume that my documentation is at least good if I got a gold card in the first place.

Yes my wrvus are in 95-99 percentile but I dont believe my epidural utilization rate is. E&Ms make up some of that Plus I am solo. A moderated sized group of 3-5 docs will have many more claims sent in on their group NPI than mine..

 

[Agast]

Thanks....my authorizations person was putting something in the claims that was getting it rejected. Biller figured it out. Whew......

Easy fix.

Glad that worked out. The checks haven’t cleared but my biller says they are listed in the portal as paid