Utilization Management
Expert articles and analysis related to utilization management.
AI Summary — Last 30 Days
Utilization management is becoming a central fault line in Medicare value-based care as congressional Democrats move to terminate CMS’s WISeR Medicare AI prior authorization model, arguing that algorithmic review could delay or deny needed care even as CMS tests whether AI-enabled UM can reduce low-value spending in Traditional Medicare (STAT). At the same time, Medicare Advantage now covers 55% of eligible beneficiaries in 2026, intensifying scrutiny of prior authorization, benefit design, and insurer/provider risk arrangements as MA becomes the dominant Medicare delivery platform (KFF). For ACOs, payers, and health systems, the strategic issue is shifting from whether UM belongs in VBC to who governs it—plans, CMS, providers, or AI vendors—and how to balance cost discipline with patient access, clinician trust, and accountability for outcomes.
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...
The unraveling of prior authorization: 5 things to know
Prior authorization has been under intense scrutiny in recent months as frustration brews among clinicians and legislators aim to curb the use of AI technology in the practice. Here are five recent d...
Congressional Democrats try to force a vote to end Medicare AI prior authorization pilot
Congressional Democrats are mounting a fresh effort to end a Medicare experiment to use AI to approve or deny care.
Senate Democrats move to roll back Medicare AI prior authorization pilot
Lawmakers introduced a resolution to end the WISeR model, which Democrats say is delaying and denying care to seniors.
Health systems join payers as early adopters of electronic prior authorization
AMA survey shows physicians, patients continue to be heavily burdened by prior authorization
AMA survey shows physicians, patients continue to be heavily burdened by prior authorization American Hospital Association
CMS launches initiative to speed electronic prior authorization adoption
The effort, part of the agency’s ambitious Health Tech Ecosystem, aims to accelerate the industry’s progress before requirements on electronic prior authorization go into effect next year.
Physicians skeptical of insurer pledges to reform prior authorization: survey
Only 33% of physicians surveyed by the American Medical Association said they believed voluntary pledges made by major insurers last year to reform prior authorization would result in any meaningful d...