Managed Care

Managed care oversight tightened this week around prior authorization and public-program payment integrity: Senate Republicans blocked an effort to terminate CMS’s WISeR Medicare AI prior authorization test, keeping the Trump administration’s experiment alive despite provider and Democratic concerns about delayed care and algorithmic denials (Healthcare Dive). At the same time, a House committee unanimously advanced Medicare Advantage prior authorization reforms, signaling bipartisan appetite to constrain MA plan utilization management even as CMS tests similar tools in traditional Medicare. For VBC leaders, the pattern is a sharper federal push-pull: CMS is expanding technology-enabled utilization controls and fraud scrutiny—including Medicaid payment deferrals to California and Minnesota—while ACOs, MA plans, and risk-bearing providers face growing pressure to prove that care management reduces waste without restricting appropriate access.