WISeR Model Introduces AI-driven Claims Review Program in Arizona

December 4, 2025

New Federal Pilot Program Targets Traditional Medicare in Arizona; Physicians Voice Concerns

A controversial federal pilot program launching January 1 will use artificial intelligence and other processes to review and potentially deny certain Medicare claims in Arizona and five other states, raising concerns among physicians about inappropriate denials of necessary care.


WISeR Program Overview


The Wasteful and Inappropriate Service Reduction program, known as WISeR, represents a significant departure from traditional Medicare's typical operations. The six-year pilot will require prior authorization for specific medical services through private companies using enhanced technologies, including AI algorithms.

Arizona joins New Jersey, Ohio, Oklahoma, Texas, and Washington in the program, which collectively covers one in five traditional Medicare beneficiaries nationwide. Approximately 744,000 Arizonans enrolled in traditional Medicare could be affected—roughly half of the state's 1.5 million Medicare enrollees.


According to federal officials, the goal of the pilot program is to cut back on fraud and abuse in Medicare. However, healthcare experts are concerned about unintended consequences.


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 five affected states, requested a halt to the program and asked that the agency "work collaboratively 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:


"While our organizations appreciate the aim of [CMS] to increase accountability, value in healthcare delivery for Medicare beneficiaries, and reduce spending on services deemed low-value or wasteful, we believe the current design of this pilot risks unintended consequences, including delayed care, reduced access, and increased burdens on both patients and physicians."

Targeted Medical Services


The program focuses on treatments federal officials identified as vulnerable to fraud and abuse, including:


  • Impotence diagnosis and treatment
  • Incontinence control devices
  • Deep brain stimulation for essential tremor and Parkinson's disease
  • Image-guided lumbar decompression for spinal stenosis
  • Skin and tissue substitutes



Federal officials characterize these services as having limited clinical value, though healthcare experts note some represent critical, time-sensitive care.


Prior Authorization Shift for Traditional Medicare


Prior authorization remains uncommon in traditional Medicare, unlike Medicare Advantage plans where the practice is standard. Arizona State University College of Health Solutions Professor Swapna Reddy emphasized this distinction, noting prior authorization creates significant administrative challenges for healthcare systems and can become adversarial.


In a 2024 American Medical Association survey, 93 percent of physicians reported that prior authorization causes care delays, 82 percent indicated that the process can lead to treatment abandonment, and an alarming 29 percent said that prior authorization had led to a serious adverse event (hospitalization, disability, or even death) for a patient in their care.

Arizona's Prohibition of AI-driven Medical Claims 


Earlier this year, ArMA 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 significantly stopper an issue physicians have identified as pervasive among private payers, it does not apply to Medicare or Medicaid coverage.


Arizona Physicians Say the Program is Coming Too Fast, With Too Few Details


Despite the program being scheduled to begin on January 1, the physician community is voicing confusion amid a lack of operational details released to date. For a program of its magnitude, the WISeR Model is advancing at a notably quick pace, especially considering its implementation lacks sufficient transparency, stakeholder input, or evidence it will improve patient care.


Read more about the WISeR Model.


Information in this article was sourced from Arizona Central (article accessible to subscribers only). (article accessible to subscribers only).

ADHS Issues Standing Orders for Flu, COVID-19 Vaccine Access

By Admin User • September 18, 2026
Statewide orders keep pharmacists and physicians authorized to vaccinate Arizonans amid uncertainty over the next ACIP meeting. Statewide Orders Cover the 2026-27 Flu & COVID Season The Arizona Department of Health Services has issued statewide standing orders supporting access to the 2026-27 influenza and COVID-19 vaccines approved by the U.S. Food and Drug Administration. Arizonans seeking a flu or COVID-19 vaccine should contact their physician or pharmacy to confirm availability. Why the Orders Were Issued Arizona pharmacists may administer vaccines recommended by the Advisory Committee on Immunization Practices, vaccines recommended by the Centers for Disease Control and Prevention for international travel, or vaccines authorized under a prescription, including a physician-issued public health standing order. With the timing of the next ACIP meeting uncertain, ADHS worked with the Arizona Board of Pharmacy to issue statewide standing orders for the flu and COVID-19 vaccines, which function as a prescription allowing pharmacists and physicians across Arizona to administer them to anyone who wants one. ADHS Medical Advisor Weighs In "Vaccines are one of the most important tools we have to protect our communities. The Influenza and COVID-19 vaccines have been proven safe and effective at preventing severe illness, hospitalization, and death. Vaccines help us limit the spread of disease, reduce pressure on our healthcare system and reduce costs," said Dr. Richard Carmona, ADHS public health medical advisor and the 17th U.S. Surgeon General. "We have issued these standing orders to ensure safe and timely access to the vaccines in alignment with scientific and evidence-based guidance." What Arizonans Should Know The standing orders do not require every pharmacy to offer vaccinations, and they do not guarantee insurance coverage for administration. Coverage and out-of-pocket costs vary by plan, so Arizonans should check with their insurance provider before scheduling an appointment. 

Arizona Asks Supreme Court to Halt Prison Health Care Takeover

By Admin User • September 18, 2026
State attorneys seek an emergency stay after lower courts reject bids to delay receivership of the prison health care system. State Makes a Last-Ditch Appeal Attorneys for the Arizona Department of Corrections, Rehabilitation and Reentry asked the U.S. Supreme Court this week to delay a court-ordered receivership of the state's prison health care system. The request comes after both a federal district court and the 9th U.S. Circuit Court of Appeals declined to pause the takeover. In the recent application, former U.S. Solicitor General Paul Clement, a representative of the department, argued that the state deserves more time to make its case before surrendering control of its operations, including oversight of its employees and health care budget. Roots of the Case The dispute began in 2012 when inmates sued the department, alleging the prison system's inadequate medical, mental health, and dental care amounted to cruel and unusual punishment under the Eighth Amendment. The case went through years of litigation and a failed settlement agreement. In 2023, U.S. District Judge Roslyn Silver ruled that the health care system was "grossly inadequate." The court ordered the prison healthcare system to comply with more than 150 "quality indicators," but according to court-appointed monitors, the department failed to comply with 131 of the measures. In light of this finding, Silver named Annette Chambers-Smith, former director of the Ohio Department of Rehabilitation and Correction, to take over as receiver effective Oct. 19. Arguments on Both Sides Clement argues receivership should be the last resort and that Silver moved to it too quickly. He asserts that the department has made measurable progress, including growing its health care staffing by more than 50%, expanding substance-use treatment access, and adopting a new care model. Corene Kendrick, deputy director of the American Civil Liberties Union National Prison Project, which represents the roughly 25,000 people incarcerated in Arizona prisons, called the department's request a "Hail Mary" and said Silver had given the department years of opportunities to comply before ordering receivership. What Happens Next The Supreme Court has not yet set a deadline for the plaintiffs to respond to the stay request. Separately, the 9th Circuit is now reviewing the merits of the receivership order itself. The department filed its opening brief on Sept. 15, and the plaintiffs' response is due Oct. 15. Information in this article was sourced from the Arizona Mirror .