Legal
CMS Orders Corrective Action Plan from Medicare Contractor Over AI Review Delays
CMS required Virtix Health, the contractor operating the WISeR Model in Washington, to submit a corrective action plan after failing to meet 72-hour turnaround requirements for prior authorization and prepayment determinations. The enforcement action follows findings that the company's AI-assisted review processes did not comply with statutory timeframes. While the WISeR Model applies to Medicare fee-for-service, the action signals CMS's expanding scrutiny of automated utilization management tools and could inform future oversight of similar technologies in managed care programs.
Why it mattersCMS enforcement of AI review timelines in Medicare establishes compliance expectations that could extend to Medicaid managed care plans using similar automated prior authorization and utilization management technologies.