Payer Strategy & Utilization
Expert articles and analysis related to payer strategy & utilization.
AI Summary â Last 7 Days
Medicare Advantage oversight and utilization management moved to the center of payer strategy this week, with bipartisan House legislation targeting MA prior authorization and denial practices while CMSâs 2027 MA final rule simultaneously strengthens some consumer protections and rolls back othersâcreating a more complex compliance and contracting environment for plans, providers, and risk-bearing groups. Scrutiny of AI-enabled utilization management intensified as Sen. Maria Cantwellâs report said CMSâs WISeR Medicare AI prior authorization pilot in Washington is delaying care from roughly two weeks to four-to-eight weeks, underscoring the tension between administrative efficiency, access, and downside-risk performance in VBC arrangements (Healthcare Dive). At the same time, evidence from the Oncology Care Model showing reduced chemotherapy use and lower Medicare spending in poor-prognosis cancers reinforces that specialty VBC models can curb low-value careâbut only if payer UM policies and model incentives align around clinically appropriate de-escalation rather than blanket denial management (AJMC
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Technology alone won't resolve prior authorization issues
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Digitizing Medical Policy Alone Will Not Automate Prior Authorization at Scale  MedCity News
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Payers promise standardized electronic prior auths  TechTarget