Utilization Management & Prior Authorization
Expert articles and analysis related to utilization management & prior authorization.
AI Summary â Last 30 Days
Synthesis:
In the last 30 days, CMS under the Trump administration has intensified its focus on technology-driven utilization management, notably with the WISeR (Wasteful and Inappropriate Service Reduction) Model mandating AI-powered prior authorization across six statesâa move that, while aimed at curbing unnecessary services, is triggering mounting criticism from lawmakers and providers over care delays and heightened administrative burden for Medicare beneficiaries (Healthcare IT News, STAT News). Concurrently, major payers are accelerating efforts to standardize and automate prior authorization workflows, seeking operational efficiencies that may ease friction for ACOs and value-based care organizations, but risk exacerbating tensions around access and provider flexibility (Healthcare Finance). These dynamics underscore a broader shift toward algorithmic oversight in utilization managementâa trend with significant implications for risk-bearing providers and the future of population health strategy.
Related Articles
âPrior Authorizationâ Has Become a Dirty Word in Healthcare, But it Might Be Medicareâs Smartest Path Forward
âPrior Authorizationâ Has Become a Dirty Word in Healthcare, But it Might Be Medicareâs Smartest Path Forward  MedCity News
Contributor: Prior Authorization in 2026âCMS Is Rebuilding the Operating Model
CMS proposes electronic prior authorization for drugs
Amid ongoing implementation of federally required electronic prior authorization for healthcare items and services, CMS now proposes to do the same for pharmaceuticals. New regulations would apply to ...
Rethinking Prior Authorization for Better Outcomes
Rethinking Prior Authorization for Better Outcomes  Fierce Healthcare
New Prior Authorization Proposals: Implications for Prescription Drug Access
New Prior Authorization Proposals: Implications for Prescription Drug Access  Health Affairs
UnitedHealthcare, Aetna, Cigna tout progress to standardize prior authorization as part of industry-wide commitment
UnitedHealthcare, Aetna, Cigna tout progress to standardize prior authorization as part of industry-wide commitment  Fierce Healthcare
Health plans adopt standardized approach to prior authorization
Health plans have announced a new initiative to adopt a standardized approach for electronic prior authorization requests, according to AHIP.The standardized approach will be used for medical services...
Cigna, Humana standardizing some prior authorization requirements
Cigna, Humana standardizing some prior authorization requirements  Modern Healthcare
Medicare AI prior authorization pilot delaying care in Washington: report
The report compiled by Sen. Maria Cantwell, D-Wash., found procedures in the state that were previously approved in two weeks now take four to eight weeks to be authorized.
Health Plans Take Next Step to Streamline and Simplify Prior Authorization for Patients and Providers
Health Plans Take Next Step to Streamline and Simplify Prior Authorization for Patients and Providers  AHIP