Problems with seniors' access to health care have arisen just four months into a federal pilot program that uses AI to review certain Medicare claims in six states, including Arizona.
The six-year program, called Wasteful and Inappropriate Service Reduction, or WISeR, launched Jan. 1 in New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington. Some providers and a group of Democrats in Congress tried to put a stop to the WISeR program before it launched, but their efforts were not successful.
The WISeR program makes use of "leveraging enhanced technologies" operated by private for-profit companies to authorize — and possibly deny — certain medical care for people enrolled in traditional Medicare, often also known as original Medicare. The enhanced technologies include AI.
A snapshot report of the program compiled by Sen. Maria Cantwell, D-Washington, using new data from the Washington State Hospital Association, shows that patients dealing with the new federal program are waiting two to four times longer to get the care recommended by their doctors, from a previous average of around two weeks to the current average of four to eight weeks.
People are also reading…
Arizona seniors reportedly are having similar problems.
Sen. Ruben Gallego, D-Arizona, told The Arizona Republic in an emailed statement April 28 that his office has had "several reports of claims being denied with no explanation and providers having to resubmit claims multiple times to finally get approval."
The "unnecessary red tape" is delaying care and making it harder for seniors on traditional Medicare to get the treatment they need, Gallego wrote.
“This is what happens when the administration makes unilateral decisions without listening to what providers need," his statement said. "My office is continuing to monitor the rollout closely and push back on any policy that makes it harder for Arizonans to get care.â€
The pilot is a significant shift for traditional Medicare. Prior authorization, which means a determination process where an insurer decides whether a health service is medically necessary, is rare in traditional Medicare.
Cantwell, on April 27, wrote a letter to U.S. Health and Human Services Secretary Robert F. Kennedy Jr. that says the pilot program "is not meeting expectations in Washington state."
Sen. Mark Kelly, D-Ariz, in 2025, criticized the WISeR program as a way for AI companies to profit off of denying care to seniors. He reiterated that opinion in an April 27 emailed statement to The Arizona Republic that said "AI companies shouldn't profit from denying care for seniors" and that health care decisions should be between patients and their doctors.
"There needs to be accountability to make sure Arizonans can get the care they need without unnecessary delays," Kelly said.
An April 27 emailed statement to The Arizona Republic from Abe Sutton, Innovation Center Director for the Centers for Medicare & Medicare Services or CMS, said CMS is closely monitoring the performance of the WISeR pilot and "will take corrective action if any part of the model creates inappropriate barriers to access."
Cantwell: Patients suffering delayed care, prolonged pain
The six states that are part of the pilot program collectively are home to one in five traditional Medicare beneficiaries, according to a perspective about WISeR published Sept. 25 in the New England Journal of Medicine.
Officials with the CMS have said the pilot is designed to protect taxpayers. They said it will cut down on wasteful spending in Medicare, which is a program primarily for people over the age of 65, certain young people with disabilities and people with end-stage renal failure.
WISeR is "about protecting Medicare patients from unnecessary and potentially harmful procedures and redirecting them to clinically-supported, high-value care," and that "early implementation comes with operational adjustments," Sutton wrote.
According to Cantwell, a senior member of the Senate Finance Committee and ranking member of the Senate Committee on Commerce, Science, and Transportation, CMS committed to responding to claims in the program within 72 hours, but Washington providers report they are waiting 15 to 20 days for determinations, "which are most often denials issued without any clear justification."
Patients are rescheduling appointments and enduring prolonged pain due to the delayed determinations, Cantwell wrote to Kennedy.
About 744,000 Arizonans could be affected
Cantwell's letter also criticized the structure of the WISeR program as a model that financially rewards contractors for delaying or denying care.
"A misaligned incentive structure that claims to boost efficiency but risks restricting access for vulnerable seniors," Cantwell wrote.
The pilot includes a frequently criticized profit-sharing agreement between CMS and private tech companies, which have a profit incentive for saving Medicare money, through "averted expenditures."
CMS officials have said the payment incentives will reward "timely, accurate determinations," and participants will face penalties for "inappropriate denials" and slow response time.
About 33 million Americans are enrolled in traditional Medicare, including approximately 744,000 people in Arizona who could be affected by the new pilot. That's about half of the 1.5 million Arizonans enrolled in Medicare, according to data from KFF, an independent health policy research and polling organization.
Most of the rest are enrolled in Medicare Advantage plans, which are private, for-profit alternatives to traditional Medicare that have already come under fire, including during congressional committee hearings, for requiring prior authorization and for using AI algorithms to approve and deny care.
The WISeR program does not include all types of care, but rather a list of treatments that federal officials have deemed to be at high risk for fraud and abuse, including the diagnosis and treatment of impotence; incontinence control devices; deep brain stimulation for essential tremor and Parkinson's disease; and image-guided lumbar decompression for spinal stenosis, among others.
CMS officials say the services they chose have limited clinical value; the federal government calls this "low-value" care, though critics have said delaying those services could cause patients to suffer such as a person with excruciating pain caused by spinal stenosis who is denied access to lumbar decompression − an example cited in a perspective article by three Boston physicians published Sept. 25, 2026, in the New England Journal of Medicine.
Gallego said that prior authorization should not have a place in traditional Medicare.
"Health care providers should have the freedom to make the best decisions for their patients’ health and not be forced to take orders from an AI bot deciding what gets covered," he wrote. "That’s why I’ve been opposed to the WISeR program since the beginning."
