Utilization & Network Management
Expert articles and analysis related to utilization & network management.
AI Summary — Last 24 Hours
Utilization and network management pressures intensified as Elevance sued CMS over a $115 million Medicare Advantage Star Ratings dispute, underscoring how quality measurement methodology can materially affect MA revenue, bonus payments, and plan-provider VBC economics (STAT). At the same time, CMS’ controversial WISeR prior-authorization AI initiative drew renewed scrutiny after CMS acted against its own AI contractor, while provider-plan contracting frictions continued with CarolinaEast dropping BCBS Medicare Advantage and delaying its UnitedHealthcare exit—signals that access, network adequacy, and administrative burden are becoming more immediate operational risks for ACOs, MA plans, and health systems managing attributed populations (Becker’s
Related Articles
CMS Slaps Its Own A.I. Contractor in Controversial WISeR Program
CMS Slaps Its Own A.I. Contractor in Controversial WISeR Program  HEALTH CARE un-covered
CMS Slaps Its Own A.I. Contractor in Controversial WISeR Program
CMS Slaps Its Own A.I. Contractor in Controversial WISeR Program  HEALTH CARE un-covered
Streamlining Prior Authorization: Strategies for Securing Timely Access to New RRFL Regimens
Medicare and Medicaid Enrollees in Many High-Need Areas May Lack Access to Medications for Opioid Use Disorder, OEI-BL-23-00160 - Office of Inspector General (.gov)
Medicare and Medicaid Enrollees in Many High-Need Areas May Lack Access to Medications for Opioid Use Disorder, OEI-BL-23-00160Â Â Office of Inspector General (.gov)
CarolinaEast drops BCBS Medicare Advantage, delays UnitedHealthcare exit
CarolinaEast drops BCBS Medicare Advantage, delays UnitedHealthcare exit  Becker's Hospital Review
Week in Washington 07/02/26
Lawsuit Challenges Work Requirements – 24 States and the District of Columbia filed a lawsuit challenging CMS’ interpretation of the recently released work requirements. In particular, the lawsuit foc...
Jackson Hospital avoids July 1 closure as Blue Cross talks continue
Jackson Hospital avoids July 1 closure as Blue Cross talks continue  Healthcare Finance News
Allegheny Health Network, Heritage Valley finalize combination in Pennsylvania
The deal brings Highmark Health-owned AHN’s hospital count to 16. The combined system will invest about $285 million over the next decade to bolster Heritage Valley’s facilities.
Humana Statement on our Contract with The Ohio State University
Humana Statement on our Contract with The Ohio State University  Humana