Utilization Management
Expert articles and analysis related to utilization management.
AI Summary — Last 30 Days
The Trump administration’s WISeR Medicare AI prior authorization pilot has become a flashpoint over whether utilization management can be modernized without delaying care: Senate Republicans blocked Democrats’ bid to repeal the pilot, while Democrats continue pressing CMS for more transparency on approval/denial data, beneficiary impact, and vendor oversight (Senate vote; data request). For ACOs, MA plans, and risk-bearing providers, the signal is that CMS under Administrator Dr. Mehmet Oz and CMMI Director Abe Sutton is not backing away from tech-enabled UM, but political pressure is likely to force tighter guardrails, auditability, and corrective-action mechanisms—especially as MA prior authorization reform also advances in Congress and star ratings litigation continues to shape plan incentives.
Related Articles
Medicare Advantage Insurers Deny Prior Authorization Requests for Post Acute Care at Substantially Higher Rates Than the Overall Denial Rate
Two recent reports find that Medicare Advantage organizations deny prior authorization requests for long-term care hospital, inpatient rehabilitation hospital, and skilled nursing facility stays at hi...
Senate Republicans block effort to repeal Medicare AI prior authorization pilot
Senate Republicans block effort to repeal Medicare AI prior authorization pilot Becker's Hospital Review
STAT+: GOP blocks effort to end Medicare test of AI prior authorization
The Trump administration is testing the use of AI in Medicare to approve some medical services.
Statement on House Subcommittee Approval of the Improving Seniors’ Access to Timely Care Act
Premier applauds the House Energy and Commerce Health Subcommittee for advancing bipartisan legislation to modernize prior authorization for Medicare Advantage patients.
Democrats push for more data on Medicare AI prior authorization pilot
The letter to the CMS from Democrats is the latest salvo from lawmakers concerned that WISeR is delaying care to Medicare beneficiaries.
Medicare Advantage organizations are denying some post-acute care at high rates
Medicare Advantage’s prior authorization process is still a “Wild West,” one expert says.
One year later, insurers hedge on prior authorization pledge
One year later, insurers hedge on prior authorization pledge Modern Healthcare
Insurers Hedge on Trump-Backed Pledge To Improve Denials Process
Last year, the Trump administration announced a voluntary commitment by dozens of insurers to improve a process called prior authorization, which often requires patients or their doctors to seek appro...
Healthcare Groups Praise Unanimous Committee Approval of MA Prior Auth Bill
Healthcare Groups Praise Unanimous Committee Approval of MA Prior Auth Bill MedCity News
Democratic bid to end WISeR prior authorizations program fails
Democratic bid to end WISeR prior authorizations program fails Modern Healthcare