Utilization Management & Authorizations
Expert articles and analysis related to utilization management & authorizations.
AI Summary — Last 30 Days
Synthesis: In the past month, utilization management and prior authorizations have been at the center of federal and state policy changes impacting value-based care stakeholders. CMS finalized new requirements mandating public reporting of prior authorization metrics across Medicare Advantage, Medicaid, CHIP, and ACA exchange plans, aiming to increase transparency after years of provider frustration and to facilitate more informed oversight and payment model evolution (Becker's ASC: prior authorization by the numbers). At the same time, leading insurers have reported only modest (11%) reductions in prior authorization volume since last year’s voluntary commitments, highlighting ongoing tensions as payers balance the shift to lower-cost settings under value-based arrangements with persistent utilization controls (Healthcare Dive). These developments underscore the strain between policy objectives to reduce administrative burden in VBC models and operational realities of payer oversight, while new data transparency rules could drive further structural reforms.
Related Articles
Administrative burden is driving severe physician burnout
You trained for years to become a physician so you could heal people. Yet every day, you find yourself fighting the very system that is supposed to support you. A patient presents with classic symptom...
CMS proposes easing prior authorizations for prescription drugs
CMS proposes easing prior authorizations for prescription drugs Modern Healthcare
CMS releases proposed rule establishing electronic standards for drug prior authorizations
CMS releases proposed rule establishing electronic standards for drug prior authorizations American Hospital Association
Prior authorization by the numbers: 10 stats that show the strain
A 2024 CMS rule now requires payers, including Medicare Advantage plans, Medicaid, CHIP and ACA exchange carriers, to publicly report prior authorization metrics for the first time. The public report...
Insurers have Cut Prior Auth by 11% Following Commitments
Insurers have Cut Prior Auth by 11% Following Commitments MedCity News
Insurers Cut 11% of Prior Authorizations, Expand Continuity-of-Care Protections
Insurers have cut prior auth requirements by 11%: AHIP-BCBS
Insurers have cut prior auth requirements by 11%: AHIP-BCBS Becker's Hospital Review
Group cutting prior authorizations by 11% includes Aetna, Cigna
Group cutting prior authorizations by 11% includes Aetna, Cigna Modern Healthcare
Insurers have eliminated 11% of prior auths under reform pledge
Insurers have eliminated 11% of prior auths under reform pledge Fierce Healthcare
How to win peer-to-peer calls: a medical director’s guide
I review your peer-to-peer calls. Here is why you keep losing. I sit on the other side of your peer-to-peer call. I am a physician medical director in utilization management. When you call to overturn...