Utilization Management
Expert articles and analysis related to utilization management.
AI Summary — Last 7 Days
Utilization management pressure intensified around Medicare Advantage, with KFF reporting that MA now covers 55% of eligible Medicare beneficiaries in 2026 while companion analysis underscores continued reliance on prior authorization—raising the stakes for providers, ACOs, and risk-bearing groups that must manage access, documentation, and downstream total cost of care within MA-heavy markets (KFF enrollment update; KFF prior authorization analysis). At the same time, CMS enforcement and reform momentum are converging: CMS suspended enrollment for a Maryland MA plan over enrollee harm concerns, ACP called for MA reforms centered on patient access, and WISeR continues drawing provider pushback—signaling that under the Trump administration’s CMS, led by Administrator Dr. Mehmet Oz, UM oversight, AI-enabled prior auth, and VBC model design are becoming increasingly linked operational and policy risks for payers and providers.
Related Articles
Providers not seeing prior authorization improvement
Amid promises from health plans that they have dialed back their use of prior authorization, hospitals and health systems are not seeing any reduction in their use, say advisers. In April, health plan...
The missing piece in prior authorization reform? Providers, some argue.
Prior auth reform is being, well, reformed.
WISeR continues to face pushback
From newsletter: Weekly Health Tech Reads 5/31/26 Weekly Health Tech Reads 5/31/26 Musing on $100 billion healthcare AI companies, the impact of GLP-1s, conversations about primary care access, and mo...
Massachusetts prior auth regulations take effect: 6 things to know
Massachusetts prior auth regulations take effect: 6 things to know Becker's Payer Issues
The 72-Hour Hurdle: Faster Prior Authorization is Exposing Healthcare’s Broken Billing Cycle
The healthcare ecosystem is fixing how quickly decisions get made, without fixing how quickly money actually moves. This isn’t a failure of reform. It’s evidence that reform is working — and revealing...
UnitedHealthcare vows to cut down use of prior reviews for kids' care
UnitedHealthcare vows to cut down use of prior reviews for kids' care AOL.com
UnitedHealthcare to eliminate prior authorization for 30% of services
UnitedHealthcare to eliminate prior authorization for 30% of services AOL.com
Shape the Future of AI in Prior Authorization: Apply to Join NCQA’s Learning Collaborative
Artificial Intelligence (AI) is rapidly reshaping health plan operations. While some organizations are actively piloting or scaling AI solutions, others are still determining where to begin. Regardles...
Prescription Drug Prior Authorization: Costs to Pharmacies and Physicians
Major insurers share prior authorization requirements for just 14% of services: Study
Major insurers share prior authorization requirements for just 14% of services: Study Becker's Payer Issues