Payer Coverage Management
Expert articles and analysis related to payer coverage management.
AI Summary â Last 30 Days
Payer coverage management is moving from an operational pain point to a central Medicare Advantage and VBC policy battleground: bipartisan House legislation is targeting MA prior authorization and denial practices, while the AHA and other provider groups are aligning behind broader reforms that would curb plan discretion and strengthen transparency, appeals, and continuity-of-care protections. At the same time, CMS under the Trump administration is advancing prior authorization modernization while facing political pushback over the WISeR Medicare AI prior authorization pilot, after a Washington report found authorizations that previously took two weeks now taking four to eight weeksâraising concerns that automation could worsen access friction unless tightly governed. For ACOs, MA-contracted providers, home health operators, and risk-bearing groups, the strategic implication is clear: utilization management, AI review, and denial governance are becoming core performance and compliance capabilities, not just payer-relations issues, especially as MA scrutiny intensifies following the $117.7 million Aetna false claims settlement
Related Articles
AI-powered prior authorizations for Medicare have greatly delayed care, Washington state hospitals say
AI-powered prior authorizations for Medicare have greatly delayed care, Washington state hospitals say  Fierce Healthcare
MedCity Pivot Podcast: Modernizing Prior Auth
MedCity Pivot Podcast: Modernizing Prior Auth  MedCity News
AI supports coverage decisions, but humans hold the line
Federal mandate sheds new light on prior authorizations
Federal mandate sheds new light on prior authorizations  Modern Healthcare
The Growing Challenges in Hospital Pre-Authorization
The Growing Challenges in Hospital Pre-Authorization  AAPC
How are payers and providers using AI? And why isnât AI reducing administrative cost?
The Peterson Health Technology Institute (PHTI) recently released a report titled: âAdministrative AI: Current Use and Potential Impact.â The report was based on a workshop PHTI convened with senior l...
Elevance Health seeing shift to bronze tier in ACA plans
Elevance Health seeing shift to bronze tier in ACA plans  Fierce Healthcare
STAT+: Federal test of AI prior authorization is delaying care for seniors, report says
A new Medicare prior authorization test is delaying care at Washington state hospitals â and should be scrapped, senator says.
ACA enrollment declines as fewer enrollees pay their premiums
Affordable Care Act enrollment in 2026 declined by 17% to 26%, according to a Wakely Consulting Group report.
ACA exchanges will continue to shrink as fewer enrollees pay premiums, analysis suggests
About 14% of ACA enrollees didnât pay premiums in January, a higher rate than usual and one that suggests ACA enrollment will continue to decline, according to Wakely.