The Human Cost of Automated Denials: A Wound Care Team's Experience With WISeR

Key Takeaways 

• In the speakers’ experience, AI-generated denial rationales in the WISeR system did not match the clinical documentation. Providers described repeated denials that cited missing or unsupported criteria even when the required wound history, conservative treatment failures, and medical necessity were clearly documented in the patient chart.  
• They contend that delays caused by WISeR denials could directly harm patients with chronic wounds. The clinicians emphasized that wound care is highly time-sensitive, and prolonged authorization and appeals processes can increase risks for infection, hospitalization, tissue loss, sepsis, and limb-threatening complications.  
• They note that the appeals process creates major operational and financial strain for wound care providers. The team described spending months navigating appeals while continuing medically necessary treatment without reimbursement, highlighting concerns that the current system is unsustainable for wound care practices and inaccessible for timely patient care.  

Transcript

Alexus Castaneda: 

So we had a Medicare patient that had two separate wounds. One was on the left foot and one was on the right elbow and upper arm area. We had originally submitted a prior authorization request with Cohere for the application code, which is 15271 on the Cohere portal. And that request was tied specifically to the patient's left foot wound. And after we submitted all medical records and documentation, our request was non-affirmed, basically meaning they denied our prior authorization. One issue with this non-affirmation was that the rationale was not accurate. The letter they provided stated that our notes supposedly showed that the provider planned to use wound care products for more than a 12-week period, but our notes did not state that. The request we submitted was for eight units, no more than 10. And also the clinical notes had said grafting would be considered only after conservative care was suboptimal or if the patient remained eligible. 

That's very different from saying that we plan to exceed Medicare's treatment limits. Later, the service at issue was for the patient's right elbow or the upper arm area and not the left foot because the wound on the foot had already healed too much so we didn't need to graft it anymore, but now we had this new wound. So the claim denial we received was not really a clinical denial saying that the elbow graft was unnecessary. It was a coding or claim linking denial. So for Wiser, they only require authorizations for lower extremity wounds, not upper extremities. So for this wound, we didn't have to submit a prior authorization. However, Medicare still denied our claim because the application code was not recognized on the claim and apparently it was split from the original claim submission due to not having the prior authorization number listed. And when we spoke with a Medicare representative, we explained how an authorization isn't required for this wound and we were told to leave that filled blank, but we're still having issues with the claim being separated and then still wanting a prior authorization code, even though that's not required. 

Amber Metoyer: 

I think we realized that this wasn't a typical denial when the rationale being returned didn't accurately reflect what was actually documented in the chart. So as an advanced provider, I'm used to insurance requesting clarification or additional clinical support, but this felt different because the denial language appeared to be disconnected from the patient's chart. We had documentation in the records that we submitted showing wound history, measurements, conservative treatment attempts, wound bed descriptions, lack of sufficient progress that we had documented and the clinical rationale as to why we felt that this was an appropriate advanced therapy. Yet when the denial would come through, it would state things like conservative care wasn't demonstrated or the wound bed preparation was inadequate or the wound didn't meet criteria even when those elements were clearly present in the charting and documentation that we had sent through with the prior authorization. So it wasn't simply that it was disagreeing with our recommendation, but that it was denying seeming to ignore or misread the records that were in front of it. 

And so when the same type of inaccurate rationale appears in other prior authorization denials, it raises concern that it's not an individualized clinical review, but it's a system level process issue that's driven by the automation and AI not being completely fixed and corrected and worked out with all the kinks. It's producing denials without any meaningful clinical interpretation. So I would say it's a red flag because the denial rationale, it doesn't match the chart. So when a denial is telling me that something is missing and I can point directly to the chart where it's stated that it's not, that's a process issue with reviewing the patient's clinical reality, it's not an issue on our end. 

Lance McNeill: 

I think they have a name for that in the world of AI. They call it hallucinations where it presents information that can't be traced back to an original source and where the original source says something completely different. And that's a big problem I think when we are using AI to make treatment determinations for Medicare beneficiaries. I'm going to broaden beyond the question for a moment and just ask the question, how is that allowed to happen? I think they introduced this wiser AI technology relatively quickly. I mean, we probably all use AI in our day-to-day work. We see how quickly it has improved and how useful it can be, but we also, everyone is seeing the limitations, hallucinations being one of them. And when you have such a high stakes thing like determining someone's medical care, it can't just be rolled out without really testing beta testing. 

And I don't see that that has happened. They rolled out WISeR as a pilot program, but the pilot program spans six years and it affects, I can't remember if it's six or eight states. That's not a pilot. That's an implementation of a program, a technology. A pilot is when you test something at a very small scale and you refine it and you learn from mistakes and you improve that over time before you roll that out. This is a rollout. It's a limited rollout, but it still affects potentially thousands of patients across these states and thousands of Medicare beneficiaries. So that's one of the issues that I have. Another technical issue that I think Alexis ran into was that the prior authorization was submitted with a patient who had multiple wounds. The technology and the process behind it wasn't able to discern between a wound that was out of scope, that being the elbow wound, and a wound that was within scope of WISeR. 

So you really have two problems here as well. You have the hallucination and then you just have the inability to discern a unique case or an outlier case where you have ... I mean, it's not that much of an outlier. We have a lot of patients with multiple wounds. So my guess is that a lot of other wound care companies have probably run into this issue too when they've had a patient with multiple wounds. So that's another challenge. 

Amber Metoyer: 

I'd say that the practical impact has been significant for the clinical team, for the patients. It creates a major administrative burden. Advanced providers and staff are spending hours re-reviewing charts, gathering documentation, writing appeals, clarifying information that was already submitted and provided, trying to correct inaccurate denial rationales. This time would much rather be spent with direct patient care, wound assessment, coordination, plan of care for the patient. It's inefficient use of our time and it's not helpful for our patients, but who are the greater concern, the patient impact? These are not elective or cosmetic treatments. We are talking about patients with chronic wounds who have already failed conservative measures are not progressing adequately with their conservative care plan and delays in wound care mean prolonged open wounds. That's in higher risk for infection, that is worsening tissue loss, that means increased needs for antibiotics or hospitalizations. And in severe cases, it can progress to limb-threatening complications, sepsis, really much higher acute concerns that could lead to death in our patients. 

So from an advanced provider standpoint, the most frustrating part is that the denial process is interrupting the time of care because wound care is very time sensitive. When a patient is clinically appropriate for an advanced therapy like a graft in the process forces repeated delays, we lose momentum. And while we're losing momentum and we're waiting for them to give us that green light, the wound continues to deteriorate while we're waiting for that response. And whilst that's happening, it affects patients' trust because patients often don't understand why a treatment their provider is recommending to them is being blocked by their insurance. So they feel like care is being withheld and then it's left to our team to try to explain why a denial process that isn't clinically reasonable still has the final say and final authority on this. So it's not just paperwork that's the burden and it's not just every appeal represents a patient's wound remaining open and at risk. 

So the delay itself in the process becomes a part of the harm to the patient. 

Lance McNeill: 

I think I appreciate Amber laying out the clinical impact and I'll speak to the business impact and administrative impact as well. So when we saw the denial and we saw that it was caused partly by a limitation of the technology combined with a process limitation, Alexus called Medicare and spoke to a representative from Novitas and they basically told her there's nothing that we can do, just go through the appeals process. That's why it's there. And that seems to be what the WISeR implementation is relying on. Are there going to be mistakes and limitations and errors with the technology? Yes, of course. But WISeR’s response is that, well, you've got a due process for that, and it's the regular Medicare appeals process. But unless you've gone through that process, you don't quite have appreciation for how difficult it is to get something overturned even when you are in the right and even when you are just in having that overturned. 

And so we submitted an appeal after that denial after Alexis called Medicare and that appeal was denied at the first level and now we are escalating that to the qualified independent contractor. When you look at the rates for qualified independent contractors overturning those decisions that came down from upstream, the rates are very low. I think they overturn about 5% of everything they review, they overturn in the favor of the provider. 95% of the time they just upheld the decision that came to them from upstream. And there's a whole other episode where I can opine on why I believe that's the case, but the reality is now we have to escalate again to beyond the qualified independent contractor level to the administrative law judge level. And that's the first time that we will have an opportunity to speak to a human being who is empowered to make a judgment on what has happened and who is giving us enough time and attention to actually hear the facts of the case. 

Those meeting s... I've been in those hearings quite often. They usually last about an hour. The judge is just listening to the facts and the common sense that you're presenting. When you call Medicare, you don't get that. In fact, when Alexus called Medicare, the representative yelled at her and said, "It doesn't matter. Just go through the appeals process. There's nothing I can do. " And they just put the problem on the conveyor belt, they send it downstream and you're left to take care of it at the ALJ level. The problem is to get to the ALJ level and to get through all these appeals levels, it takes time, it takes money. And of course we haven't been paid for the treatment that we've provided this patient and we didn't just stop the treatment for the patient. We went ahead and continued the treatment because it was appropriate. 

It was the right thing to do and we're eating the costs of that now. The patient's not paying for it. They're not allowed to pay for it according to Medicare. And so we are paying for that. This was a treatment we provided back in February and we're in May now and that's all cashflow. We've already paid for the cost of goods sold. For those skin substitutes, we've already paid for the labor for our providers to go out there and provide that treatment. So that's three months of a cashflow problem for our business. And then you also have the expected timeline. We're only at the quick level. It's going to take 60 days for them to make a determination. Then we have 30 days to appeal to the ALJ. They take usually two to three months to schedule those just based on their backlog. We may not be speaking to a human in the loop from a decision that was made by an artificial intelligence. 

We may not have the opportunity to speak to the right human in the loop until toward the end of this year as a best case scenario. That is unsustainable. It's a bit dystopian when you think about healthcare and everything that Amber laid out in terms of the worst case clinical outcomes and it needs to be fixed. And the reason why we're here today speaking to your audience is so we get our voice out there, we get this patient's experience out there and hopefully decision makers and other stakeholders will listen to our story and make the necessary changes. I did reach out to Wiser and asked how are they evaluating the Wiser program, the AI? And they said they're going to make their first assessment in August to see how the program has been going. So they'll be looking at the first seven, eight months of the program. 

It takes just a handful of days for AI to deny this patient's care, but it's going to take eight months for Medicare to look and see what's going on. That feedback loop is unacceptable and we need reform and we need it much more quickly than we're getting it. 

Alexus Castaneda: 

I think there's definitely a gap in the current WISeR model and I think the system needs a clear exception pathway for services and instances like this where we are using the same application code that we would've for the lower extremity wound, but it's for the upper extremity wound and they need to have a clear way to document that there is no prior auth number required due to the wound being an upper extremity wound and they don't right now. Just like Lance said, they just kind of say, oh, well, it'll still get denied and just go through the appeals process and you can explain yourself, but why can't we explain ourself beforehand before the claim can get denied as a pre-claim review? But instead they just waste more time and resources instead of finding an easier way to do that. 

Amber Metoyer: 

We're all really just essentially calling for reform for the WISeR program. It was clearly rolled out when it wasn't ready to be rolled out. Kinks hadn't been worked through. It really hadn't been thought through appropriately. But because if an initial denial contains inaccurate or incomplete information, our interpretation of a clinical record, then there should be a meaningful and timely way to correct that error. We shouldn't be having to go through an appeals process when it's very clear to the humans involved that this was a clerical error and not an actual determination based on the facts of the case and the reality of the patient's wound status. Models like that, it's not due meaningful process. When it comes to wound care, time matters. And so if the due process takes too long, then that's not meaningful due process, so it does need to be reformed. We're not saying that there's no case for an appeal. 

We're not saying that the issue is simply that you have to appeal sometimes. There's appeals process for reasons, they're part of the system. But when the jump off point for the system is already so flawed and then the appeals process itself is also so flawed, something has to be done because it's not working and our patients are paying the cost for it and clinics are paying the cost for it. Not many mobile advanced wound care clinics are surviving in this climate. As Lance has so wonderfully explained the backlog of cashflow, people can't just continue on that way. 

Ms. Castaneda, Ms. Metoyer, and Mr. McNeill are all affiliated with Victory Wound Care.