Utilization & Network Management
Expert articles and analysis related to utilization & network management.
AI Summary — Last 24 Hours
Prior authorization is moving from policy mandate to operational battleground: CMS is advancing changes to further incentivize FHIR-enabled electronic prior authorization under CMS-0057-F, while Epic is launching instant prior auth checks at Ochsner Health, Froedtert ThedaCare Health, Denver Health, and Summit Health—raising near-term expectations that payers and providers can reduce manual UM friction inside EHR workflows (Epic rollout). At the same time, OIG found Health Share of Oregon did not always comply with federal and state requirements when denying prior authorization requests, reinforcing that digitization alone will not satisfy regulators unless denial logic, timeliness, and appeal rights are auditable and clinically defensible (OIG finding
Related Articles
CommonSpirit’s 5 targets for judging payer prior auth reform — and its Humana milestone
CommonSpirit’s 5 targets for judging payer prior auth reform — and its Humana milestone  Becker's Payer Issues
CMS Proposes Changes to Incentivize FHIR-enabled Electronic Prior Authorization Use
CMS Proposes Changes to Incentivize FHIR-enabled Electronic Prior Authorization Use  Wilson Sonsini
10 numbers that show prior authorization is still broken
Epic debuts instant prior authorization checks at 4 health systems
Ochsner Health, Froedtert ThedaCare Health, Denver Health and Summit Health are debuting the application programming interface, which Epic says should speed up preapprovals for medical items and servi...
CMS-0057-F: Using Public Payor Prior Authorization Data
CMS-0057-F: Using Public Payor Prior Authorization Data  Forvis Mazars US
Prior Authorization Under Pressure: The Case for Clinician-Led Utilization Management
Prior Authorization Under Pressure: The Case for Clinician-Led Utilization Management  AHIP
Health Share of Oregon Did Not Always Comply With Federal and State Requirements When Denying Prior Authorization Requests - Office of Inspector General (.gov)
Health Share of Oregon Did Not Always Comply With Federal and State Requirements When Denying Prior Authorization Requests  Office of Inspector General (.gov)
Four health systems, including Ochsner and Denver Health, go live with Epic's real-time prior authorization checks
Four health systems, including Ochsner and Denver Health, go live with Epic's real-time prior authorization checks  Fierce Healthcare
'AI is never used to deny care' — on tech, trust, accuracy and prior auths
Epic rolls out prior authorization, AI outpatient tools
Epic rolls out prior authorization, AI outpatient tools  Modern Healthcare