Utilization Management & Authorizations
Expert articles and analysis related to utilization management & authorizations.
AI Summary — Last 7 Days
Synthesis:
Utilization management and prior authorization policies are entering a period of recalibration as federal rules now require public reporting of prior auth metrics across Medicare Advantage, Medicaid, CHIP, and ACA plans—placing new transparency pressures on payers (Becker’s ASC). Major insurers, including those guided by AHIP and BCBS, have pared back about 11% of prior auth requirements, but access and cost uncertainties remain acute as the latest CMS rate notice from the Trump administration directs an additional $13 billion to Medicare Advantage, potentially intensifying scrutiny on how UM and authorization decisions intersect with population health and VBC Wakely summary. Meanwhile, expanding use of AI in coverage determinations is heightening legal and ethical tensions, underscoring the need for thoughtful integration into ACO workflows and risk contracts.
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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-BCBSÂ Â 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...