AI-powered WISeR program complicates treatment for Arizona Medicare patients, doctor says

The federal Centers for Medicare and Medicaid Services this year embarked on a new pilot program, called Wasteful and Inappropriate Service Reduction, or WISeR. Arizona is one of six states taking part in the initial rollout, which is scheduled to run through 2031.

The WISeR model uses AI among other technologies to help determine whether or not certain procedures or courses of treatment are appropriate for Medicare patients.

Reporting from The Washington Post has found the rollout of the new system of prior authorization has not been smooth across all the states where it’s being used. And, an effort by some Congressional Democrats to repeal or defund the pilot recently failed.

Dr. Matthew Crooks has seen some of the problems with WISeR firsthand. Crooks is an interventional pain management doctor and director of interventional pain management with OrthoArizona; he’s also president of the Arizona Society of Interventional Pain Physicians.

He says before WISeR, he didn’t need to get prior authorizations for Medicare patients for minimally invasive procedures, although if CMS ultimately decided those procedures weren’t necessary, he it was possible he wouldn't get reimbursed for them.

He also points out he and his colleagues are used to getting prior authorization for other patients, including those on commercial insurance.

The Show spoke with Crooks earlier and asked what his experience has been working with WISeR.

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Full conversation

DR. MATTHEW CROOKS: So when we initially first heard about WISeR coming up to be implemented, which was the summer of last year, I myself and I think a lot of the interventional pain doctor community here in Arizona, knowing that we were one of the states where the implementation was going to take place, we were relatively optimistic because we were kind of hoping that we would be involved in the process and that we recognized that in all of medicine and with limited budgets and resources with Medicare, that curbing any sort of waste or fraud is paramount. And as leaders of the field and the clinicians and specialists, we could help to take a forefront in that while still taking great care of our patients.

As we got closer to the implementation date of January 2026, some concerning things developed in that really we were kind of in the dark about it completely from when we first heard about it to basically the go-live date in January. So there was very little ability to prepare and to sort of meet expectations of the program.

After implementation, also, I would say it was pretty rocky across the board. There was a period of time when it was first implemented in mid-January where we were getting just a tremendous amount of denials of requests for authorization with the program.

MARK BRODIE: So is the biggest issue then that procedures that you would like to do for your patients are being denied on the front end, or taking a long time to get them authorized and delaying the care?

MATTHEW CROOKS: Exactly, yep. So that’s how things played out, especially early on. And we have — things have gotten better, I must say, but still, it is very different than it was prior to WISeR.

It slowed down access to care. In some cases, it really shut down access to care. And when we went from a patient that when we saw them, we could get them the treatment that they needed within a week, even, it then dragged it out several weeks. And in the case of having denials of care, it would be even longer, or even not at all.

MARK BRODIE: Why do you think it is that you’re getting so many denials upfront?

MATTHEW CROOKS: So we question that ourselves. It wasn’t practice-specific to mine, or even talking with multiple different practices, it was pretty uniform.

And we were basically following the same blueprint or playbook that we always had in terms of next step of care, and then now all of a sudden, the denials are happening. And so what we saw was there was a great disconnect between the third-party authorization company that we had in Arizona and Medicare itself.

Now, there’s different third-party authorization companies for each of the WISeR states. So there’s multiple states where this is — we’re kind of considered the test state or the rollout of this. And so kind of state to state, it varied quite a bit.

MARK BRODIE: And to be clear, these are treatments that prior to WISeR had been approved?

MATTHEW CROOKS: Tried and true. Yes, so they didn’t require approval ahead of time, but for our sake, as the physician practice, there was no prior authorization requirement.

But if we were not following Medicare guidelines, then we as physicians or as practice owners run the risk of getting the right procedure for the right patient clinically, but it’s not following Medicare guidelines. So then Medicare can either not reimburse us or reimburse us and then come back and take it back.

MARK BRODIE: What role do you think AI has played in what’s been going on with WISeR?

MATTHEW CROOKS: So that is the $64,000 question, right? Because they say that there is a human kind of over-reading all of the authorization requests. Definitely AI is baked into the cake and is, for transparency, part of the process that they are promising. And that should lead to potentially efficiencies, right?

But the downside to it is that there are definitely aspects that we’re seeing that are clearly a computer. Our notes, our documentation notes requesting authorization are being fed through AI, and there are things — I will say that part of the reason why things have improved is because we’ve learned basically what we have to document that was different than before this.

And so we’ve basically adapted our learning to what is required by AI. And clearly that there’s software that is, if you want to look at the glass as half-empty, there’s software that is kind of dictating care in some ways.

MARK BRODIE: Well, it’s an interesting juxtaposition in some ways because while the federal government is using AI in this WISeR pilot, a number of states are passing laws specifically saying that AI cannot be used to deny claims or that kind of thing. So I’m wondering, just sort of philosophically, do you think there is a role for AI in this kind of thing?

MATTHEW CROOKS: I think that there is on both sides — on both the government side to, I mean, specifically to really, if they can fine-tune it. And unfortunately, we’re kind of in that pilot program phase in Arizona.

But to look at it optimistically, we do want to be able to preserve these procedures for the patients for the right indications. And the government is operating within a budgetary constraint, and these can be costly, especially if they’re used in the wrong way or overused or abused.

So I do think that there is a role for AI to help weed out the bad actors and the overuse and potentially to recoup on the fraudulent side. But I think right now, the settings have been kind of overly aggressive. And AI is so new in general, I think it’s kind of a new tool that really needs to be fine-tuned in the proper way.

The idea, I think, is that there is a person or a human kind of over-reading this or making sure that the denials are appropriate. And so hopefully that’s the case, and that may be what we’re seeing in terms of how things are getting better.

MARK BRODIE: So given all of this, I’m wondering what you make of the efforts in Congress by some to do away with WISeR and just scrap it altogether?

MATTHEW CROOKS: I did just see that, and I will admit that part of me was pretty excited about that. I do think that WISeR, when implemented correctly and if the proper guardrails and oversight are there for it, I do think that it could be a very valuable program. And I think from what I’ve heard from a couple of the other states where it’s been implemented successfully, more in the lines of like a Medicare Advantage plan type of authorization, I think that there is a pretty significant role for it in terms of curbing waste and fraud.

So rather than scrapping it, more oversight to make sure that steps are taken to not be a barrier in access to care for patients, and that the right patients can get the right treatments that they need. So I think really just having that oversight will be helpful.

MARK BRODIE: All right. Well, Dr. Crooks, thank you so much for taking the time to chat. I really appreciate it.

MATTHEW CROOKS: Thanks, I really enjoyed it.

MARK BRODIE: Dr. Matthew Crooks is director of Interventional Pain Management with OrthoArizona. He’s also president of the Arizona Society of Interventional Pain Physicians.

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