Utilization Management
Expert articles and analysis related to utilization management.
AI Summary — Last 30 Days
CMS is moving utilization management toward measurable, interoperable oversight: new prior authorization transparency requirements for Medicare Advantage, Medicaid managed care, and ACA marketplace plans—building on 2024 rules and electronic prior authorization/FHIR implementation—are forcing payers to disclose denial patterns and operational performance, with implications for network strategy, Stars/quality positioning, and provider administrative burden. Early 2025 data show why this matters: insurers denied at least 1 in 8 standard prior authorization requests across major coverage markets, with Medicare Advantage and other plan denial rates varying widely by insurer, creating new leverage points for health systems, ACOs, and VBC entities negotiating risk contracts and care-management workflows (KFF analysis; HFMA summary). The strategic tension is shifting from whether prior authorization can be used as a cost-control tool to how transparently and electronically it must operate—placing pressure on MA plans to defend variation in denials while pushing providers and VBC organizations to invest in data capture, appeals analytics, and FHIR-enabled authorization workflows.
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UnitedHealthcare to nix prior auth on 1,700 services on Oct. 1
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As part of efforts to improve prior authorization, CMS has bolstered its transparency requirements for health plans. Based on 2024 regulations that partially took effect in 2026 and are intended to pr...
Prior Authorization – The Health Care Blog
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Prior authorization denials vary widely among insurers, first-of-its-kind data shows
Denials ranged from 2% to 25% among insurers last year, according to a KFF analysis of new prior authorization data that the CMS forced insurers to release.
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ACP Urges Congress to Hit Pause on Use of AI in Prior Authorization - American College of Physicians - American College of Physicians | Internal Medicine
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Prior authorization: what physicians say, in their own words
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