Medicare's new AI experiment sparks alarm among doctors, lawmakers

[Ms. Toad]

28. It was in my post - a skin graft.

As is typical with many extremely aggressive cancer, there is a two step procedure for surgery. The first leaves a large open wound, during a 2-3 week wait for detailed pathology - since many aggressive tumors require a 1-2 cm clean margin, and it takes time to do that detailed examination.

Doctors cover that wound with a graft to minimize the risks of living with an open wound. Once there is no risk that they need a second surgery, an allograft (self-graft) is used. But that creates a second, much larger, wound so they don't generally use an allograft for the initial surgery.

So doctors need to move immediately for the first surgery, without the need for any delay associated with pre-approval to remove the bulk of the tumor so it doesn't continue to double.

The general rule for pre-approval is a 10-day delay before a procedure will even be scheduled. (My surgery was scheduled for a week after diagnosis - and doctor was upset it was delayed that much.) My daughter uses $200,000 in medical care each and every year, with a number of procedures that require pre-authorization. (She requires an MRI every year, and she is currently battling over the medical portion of her infusion (following an initial battle over the pharmaceutical portion of the infusion). That battle has been going on for more than a month. I am very familiar with pre-approval and scheduling requirements. It doesn't happen on while you drive home basis.

Because of her conditions, I am also familiar with many circumstances in which conservative therapy is not appropriate. The medication (and related procedure) my daughter is battling over put her in remission, after two years with repeated hospitalizations. Because her Mayo score is currently zero, they contend she doesn't need the medication anymore - even though the only reason her Mayo score is zero rather than 9 (as it was for much is the two years) is because of the medication. Just over example of doctors treating patients knowing more than insurance companies or AI.

And I'm my car, a history of cancer does not guarantee that even human review won't result in a life-threatening delay. The graft. I received was denied, after the fact. Had pre-approval been required, I might not be here. It was ultimately approved, but it took a month or so

I am not intimately familiar with every procedure on the list - but the fact that I have direct experience with one - and with an inappropriate denial - (and far too intimately familiar with profit-motivated denials) suggests that others would fall into the Medicare Advantage on steroids sinkhole.

Again, the government has tools to address actual fraud. They should use them, rather than turning Medicare into Medicare Advantage on steroids. There's a reason Medicare Advantage has such a bad reputation.

I am currently fine, although I had a recurrence scare earlier this year and, ironically, the doctor was reluctant to order an MRI because of his experience with insurance and Medicare Advantage.