Utilization Management

Provider groups are escalating pressure on Congress and CMS to curb administrative burden in utilization management, with ACP urging a pause on AI-enabled prior authorization and AMGA calling for reduced administrative waste—signals that prior auth automation is becoming a near-term policy flashpoint for Medicare Advantage, ACOs, and risk-bearing medical groups. The core tension for VBC stakeholders is whether AI-driven UM can reduce inappropriate utilization without worsening access, clinician abrasion, and coding/documentation burden, particularly as primary care capacity remains constrained for seniors and MA-heavy practices face growing reimbursement complexity (ACP on AI in prior authorization; AMGA issue brief).