Utilization Management & Prior Authorization
Expert articles and analysis related to utilization management & prior authorization.
AI Summary â Last 7 Days
Synthesis:
The past week saw intensifying scrutiny and debate over utilization management and prior authorization in Medicare and Medicare Advantage, with mounting evidence that CMS's AI-driven prior auth pilotsâsuch as the WISeR Modelâare causing significant care delays and denials across several states, drawing strong pushback from lawmakers and providers concerned about access and administrative burden (STAT News, Healthcare IT News). In response to growing friction between providers, payers, and CMS under the Trump administration, bipartisan legislation was introduced in Congress to reform Medicare Advantage prior auth practices, while CMS concurrently proposed new rules for standardized electronic prior authorization for both medical and pharmacy benefits, signaling an acceleration toward automation but also underscoring urgent calls to balance efficiency with patient access and provider workflow demands (HFMA).
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