Arizona Pain Specialist Says CMS's WISeR Model is Disrupting Patient Care

Arizona Physician Describes Challenges Following WISeR Model's Implementation 

In an exclusive article published by The Washington Post this week, physicians and patients weighed in on the immediate shortcomings of the Centers for Medicare & Medicaid Services newly-launched Wasteful and Inappropriate Service Reduction (WISeR) Model, which adds prior authorization requirements for select Medicare services.

The model utilizes artificial intelligence and machine learning alongside human clinical review to “reduce clinically unsupported care.”

Prior Authorization Creates Disruptions

Healthcare is suffering because of prior authorization’s shortcomings. It routinely interferes with the physician-patient relationship and delays the delivery of care, even in life-threatening situations. It creates unrealistic administrative workloads for our clinics. And, it's adding to the dire healthcare workforce shortages our state and country face.

The WISeR Model is only making matters worse. Despite the physician community's concerns about the AI-driven model, its rushed implementation, and its lack of stakeholder input, CMS launched the program on January 1.

ArMA Physician Shares WISeR-driven Challenges

ArMA member Matthew Crooks, MD — director of Pinnacle Pain at OrthoArizona and president of the Arizona Society of Interventional Pain Physicians — spoke with The Washington Post about how the model is already disrupting patient care for pain specialists.

Richard Hynds, one of Dr. Crooks' patients, suffers from severe lower back pain, for which he receives steroid epidural injections. These injections allow him to exercise, developing core strength to mitigate the pain long-term, he told The Washington Post. However, once the WISeR Model began, Hynds was repeatedly denied prior authorization for the injection. He had to wait more than a month before he was approved, suffering through severe pain throughout.

Dr. Crooks described the WISeR Model as significantly different from other prior authorization processes: “we’re seeing far, far more denials with Medicare WISeR than we’ve seen in the past with commercial insurances and Medicare Advantage.”

He also described long wait times, with medical staff sitting on hold for up to 90 minutes at a time just to schedule a peer-to-peer review. "Once scheduled, those conversations often occur about a week or more later, leaving patients waiting," The Washington Post reported.

Medical Organizations in Arizona, Other Pilot States Oppose the Program's Implementation

The Arizona Medical Association and other medical organizations nationwide have taken a prominent role in opposing the program's implementation.

In a letter to CMS Administrator Dr. Mehmet Oz, ArMA President Dr. Jason Jameson, along with medical association leaders from the other affected states, requested a halt to the program and asked the agency to collaborate with "stakeholders to design payment processes that protect the Medicare Trust Fund while achieving value, without jeopardizing patient access."

The associations argued the initiative shifts critical clinical decisions away from physicians and patients without adequate transparency, stakeholder input, or evidence demonstrating improved patient outcomes.

Arizona's Prohibition of AI-driven Medical Claims 

Last year, the Arizona Medical Association successfully advocated for state legislation to prohibit AI-driven medical claim denials. The legislation prohibits health insurance companies from relying solely on AI to deny medical claims, requiring medical directors to individually review denials and exercise independent medical judgment. The law was signed on May 12, and takes effect June 30, 2026.

The law sets a national precedent for regulating AI's use in commercial medical insurance, putting Arizona ahead in the race to ensure regulation keeps up with development and implementation. While the new legislation will put a stopper in an issue physicians have identified as pervasive, it does not apply to Medicare or Medicaid coverage.

Sources: The Washington Post