0:00
Copic was created by physicians who wanted something better. That's why we go beyond medical liability coverage, partnering with you from day one with CME accredited education and 24/7 guidance from physicians, our unparalleled defense includes support for dealing with medical board complaints and HIPAA concerns. We protect what matters most your livelihood. Here for the humans of healthcare. Here for you learn more at C, o, p, i, c.com,

0:28
I mean, it's one thing to have human beings denying claims, and it's it's already a problem in terms of people getting the health care they need. You know now it's going to be a computer system, and it's not one that's learning it's just denying claims faster so that they can save money at the expense of American seniors.

1:02
Welcome to all. Featuring lively and informative conversations with health care experts, opinion leaders and practicing physicians about the challenges facing doctors and medical practices. My name is Austin Luttrell. I'm the associate editor of medical economics, and I'd like to thank you for joining us today. In today's episode, medical economics senior editor Richard perryton sat down with Representative Greg Landsman, a Democrat from Ohio, and a member of the health subcommittee of the House Energy and Commerce Committee. They're talking about Medicare's wasteful and inappropriate service reduction model, commonly referred to as the Wiser model, which launched in six states on January 1, 2026 and uses AI to review prior authorizations in traditional Medicare. Landsman is a co sponsor of the ban AI denials and Medicare Act, and he explains why he believes the pilot needs to be stopped, why the model's lack of transparency is itself a major problem, and where he thinks AI should actually be used in healthcare instead. Representative Landsman, thank you for joining us, and now let's get into the

1:59
episode. Congressman, thank you for joining us today. Thanks for having me. And today we're going to get into a little bit of nitty gritty on some health policy here. January 1 2026 was the start for Medicare's new Accountable Care Model, known as wiser that's wasteful and inappropriate service reduction being tested in six states, including your home state of Ohio, this model has a unique characteristic relating to some procedures. Can you explain what that is?

2:26
Yeah, essentially, this administration decided to use big tech and give them a contract to deny claims to seniors, and they're, they're choosing to go after what they think will be non controversial claims, because they want to start the process of people being okay with AI denying claims. And, you know, we believe you've got to stop it immediately. I mean, it's one thing to have human beings denying claims, and it's it's already a problem in terms of people getting the health care they need. And remember, this is physicians are the ones asking for this health care for their patients. And you know now it's going to be a computer system, and it's not one that's learning. It's just denying claims faster so that they can save money at the expense of American seniors.

3:29
And as a counter proposal, you and Representative Bonnie Watson Coleman of New Jersey have introduced the ban AI denials and Medicare Act. What would that bill do?

3:40
It stops the pilot. It says, you you can't do this. And if, if they want to, you know, use AI to improve care. That's great, but they should not be using AI to deny health care. So our bill bans them from, you know, pursuing this pilot. Would it

4:01
stop the pilot entirely, or simply the the prior authorization process? It would stop the

4:08
pilot entirely, which is prior author? I mean it the pilot is using AI to deny claims in six states. We want to stop that.

4:19
Obviously, there's a process that takes place in Congress. What is the status

4:22
of the bill? It got a hearing a couple weeks ago, and hopefully we can convince the chair the committee to give us a vote, and it'll be bipartisan. It. It is, to me, something that Republicans should jump all over, Democrats too. Like, you know, I'm all about saving money. I don't think you should, you know, you know, go too hard on saving money if it means that you're going to, you're going to take health care away from from people, especially our seniors. So, you know, that's not, that's not the the priority, go after waste, to go after fraud, go after abuse. Don't go after seniors. In their care and don't use AI to deny claims. So hopefully, hopefully we get a vote.

5:05
One of the things that I think I'm I'm speaking for our audience when I say that our audience is well, familiar with the effects of prior authorization and health care. What are some anecdotes and stories that you have heard from your constituents, especially physicians and patients who may have had to deal with prior auth

5:23
I mean, the number one thing I hear is, it took forever, you know, I submitted this and then it got denied. It was absurd that it got denied. So we fought it, and we ultimately got it reversed. That's the number one thing I hear from physicians and from folks you know, their patients, and that means that they should be using AI to reduce the number of wrongfully denied claims. That that's the big issue is that, you know, for the most part, people get denied their claims and then it gets reversed because it was a bad decision, it was healthcare that the patient desperately needed. So I that's, that's where I would use AI

6:06
in regarding the six states that were selected for the trial. Have you seen any data specific to Ohio or any of the other states to explain why they were selected, or why the prior authorizations

6:17
could be a good idea? Now that's the other reason why this is a problem, and they need to, you know, pull back, and Congress should pass this bill and ban the pilot, but there's zero transparency. No one knows what's going on. I haven't found a single provider that understands how this is being implemented, why this is being implemented in these states. Is it voluntary? Doesn't seem voluntary. You know, the financial model is not no no one. It's a black box like, you know, they're literally getting paid. There's an incentive for them to deny more claims. But nobody knows what that formula is, and nobody knows what the AI coding is. So they don't, you know, it's one thing to have again, a human being saying no, because you can question that human being. We can't even see what the lines of code are, so there's no transparency around this.

7:13
This might be a little deep in the weeds, but our audience does pay attention to some of the different to all the different payment models that come out of CMS, the Wiser electronic portals went live on January 5. Are you aware of any Medicare payment model that has been affected retroactively by an act of Congress?

7:31
No, I'm not. But you know, this is part of the issue is that there's, again, an enormous amount of confusion. I mean, just at the moment, it's like, you know, yes, there's this really serious question about whether or not you want to use AI to deny people health care. But then there's just the execution of this pilot, which has been just, you know, very chaotic,

7:56
apart from Wiser because their prior authorization takes place both with Medicare, I should say, with Medicare Advantage and other private insurers, apart from the Wiser model, what would you like to see for prior authorization reforms across us?

8:09
Healthcare? Full transparency? I think everyone should know exactly what's going on, and I think they the rate of getting this wrong, which happens all the time, has to be reduced, right So, like you know, wrongfully denied claims that that percentage has to be going down. That should be an expectation for anyone receiving public money. You

8:44
Keith, hey there. Keith Reynolds here and welcome to the p2 management minute in just 60 seconds, we deliver proven, real world tactics you can plug into your practice today, whether that means speeding up check in, lifting staff morale or nudging patient satisfaction north. No theory, no fluff, just the kind of guidance that fits between appointments and moves the needle before lunch. But the best ideas don't all come from our newsroom. They come from you got a clever workflow, hack an employee engagement win, or a lesson learned the hard way. I want to feature it. Shoot me an email at K Reynolds at mjh, life sciences.com, with your topic, quick outline or even a smartphone clip. We'll handle the rest and get your insights in front of your peers nationwide. Let's make every minute count together. Thanks for watching, and I'll see you in the next p2 management minute in

9:36
late 2025 early 2026 of course, there's been a lot of debate in Washington about the premium tax credits that had affected some patients and people who were getting their insurance through ACA marketplaces, there has been again, additional debate in early 2026 is there a chance that's going to get an extension? Is going to get off the ground, or is that issued dead in the water? Right now?

10:01
Yeah, I hope it does. I mean, you know, I've, I've got 32,000 people my district that needed to get done, and they come first. The politics has to be, you know, you know, put to the side. And, I mean, I really, truly believe that. I mean, 22 million Americans rely on this. So, you know, if there's a glimmer of hope, we got to keep going and we passed it out of the house. We forced a vote on a three year extension, and now the Senate's got to do its job. It seems like they're going to, they're going to, you know, kill this thing. But, you know, it's a terrible, terrible thing politically for them, you know, for Republicans to try to own this, it's, it's a hugely popular thing. I don't know why they're doing that, but whatever, whatever we can do to get it done, like, you know, even if it takes the political issue off the table, all I care about, honestly, and I think most of my colleagues feel the same way on my side of the aisle, just get it done. 22 million people, Americans, rely on the Affordable Care Act, and if they don't get this done with that percentage of people, you know, you know, losing their health care because they can no longer afford it. Or I should say that percentage of people who are going to see their health care costs skyrocket, and then there's going to be a big percentage of people who lose their health care. That means people will die. It's not hyperbolic, people will die. And so if there is any chance of the Senate getting it done, they've got to lock in and get it done.

11:35
Those tax credits were a big part of a plan known as common ground 2025 a bipartisan healthcare framework. What are some of the key provisions of that plan that you would like physicians to know about? I mean, the biggest one

11:46
is the extension of the Affordable Care Act that that is the key people go to the marketplace to get, you know, health insurance with fewer and fewer employers providing health care for their for their employees, and more and more people who are working on their own, or their farmers or their small businesses, and they rely on the Affordable Care Act marketplace. But health care has gone up to such an extent that the subsidies are the only way they're able to cover the cost of health care. And so you know that, to me, is a big piece. The PBM reform is a big piece. You know, we need transparency with these providers, these folks who just buy and sell prescription drugs on behalf of different entities, and they, you know, they charge an enormous markup for that, and those savings need to be passed on to patients.

12:42
The common ground 2025 plan also did touch on potential reforms or changes in the Medicare Physician Fee Schedule. What would that entail? I don't know

12:53
what was in that text. I was focused on the Affordable Care Act piece more than anything else in the PBM reform. But the you know, the physician, you know, payment issue, to me, is a huge part of fixing the health care system. You got to pay doctors more. You know, they're not getting paid what they used to get paid, and they're not getting paid what they need to get paid, and it's causing huge problems in the healthcare system.

13:22
One of the questions I always like to ask our main audience is primary care physicians. What would you like to say to them? Or what would you like them to know

13:32
that I am a huge fan, I love my physicians, and you know you are still one of the most trusted professions in in the country, in the world, and people, you know, look up to physicians, and I think people are starting to appreciate that they are stuck, you know, in this really terrible position where they're getting paid less and they're being asked to do A whole lot more under, you know, a ton of pressure, and having to deal with all kinds of nonsense like, you know, the denial of the health care that they're trying to provide to their patients, and then all these new laws by politicians telling them what kind of health care they can and can't provide. So, you know, this is a tough time for physicians, and they've got big supporters, and I'm one of those supporters.

14:24
I'm Richard payer chin, reporting for medical economics. My guest today has been representative Greg Landsman, a member of the health subcommittee of the House Energy and Commerce Committee, and a sponsor of legislation that would stop prior authorizations in traditional Medicare. Congressman, it's been a great discussion. Thank you for joining us, and hopefully we'll get to talk again soon. I love it. Thank you once again.

14:53
That was representative Greg Landsman of Ohio speaking with medical economics senior editor Richard payerton on behalf of the. Whole medical economics and physicians practice teams, I'd like to thank you for listening to the show and ask you please subscribe so you don't miss the next episode. As always, be sure to check back on Monday and Thursday mornings for the latest conversations with experts, sharing strategies, stories and solutions for your practice. You can find us by searching off the chart wherever you get your podcasts, and if you'd like the best stories that medical economics and physicians practice published delivered straight to your email six days of the week. Subscribe to our newsletters at medical economics.com and physicians practice.com off the chart, a business of medicine podcast is executive produced by Chris mazzolini and Keith Reynolds and produced by Austin Luttrell. Medical economics and physicians practice are both members of the mjh Life Sciences family. Thank you.