Utilization & Network Management
Expert articles and analysis related to utilization & network management.
AI Summary — Last 30 Days
CMS’s WISeR Medicare AI prior authorization pilot has become a flashpoint in the broader fight over utilization management, with Democrats demanding more transparency on potential care delays while the House Appropriations Committee moved to block the program—signaling that AI-enabled UM in Medicare will face heightened political, operational, and beneficiary-protection scrutiny before it can scale. At the same time, Medicare Advantage remains structurally central to VBC strategy, with 55% of eligible beneficiaries enrolled in MA in 2026, intensifying stakes around prior authorization reform, OIG compliance guidance, star ratings litigation, and network-management practices that directly affect risk-bearing providers and payer-provider partnerships. For ACOs, health systems, and MA-aligned groups, the strategic takeaway is that utilization control is not going away, but its legitimacy will increasingly depend on transparency, clinical governance, appealability, and evidence that UM tools support—not obstruct—value-based care outcomes (WISeR scrutiny; MA enrollment trends).
Related Articles
AASM submits comments on CMS interoperability and prior authorization proposed rule
On April 14, 2026, the Centers for Medicare & Medicaid Services (CMS) published the Interoperability Standards and Prior Authorization for Drugs Proposed Rule, representing a significant step toward m...
the House Appropriations Committee voted unanimously
From newsletter: Weekly Health Tech Reads 6/14/26 Weekly Health Tech Reads 6/14/26 Musing on Hawai'i's VBC conundrum, 2032 as a healthcare election, Hinge's investor day, Abridge's bid to be a clinica...
OIG: 3 Largest MA Insurers Deny Prior Auth Requests at High Rates for Long-Term Acute Care, Inpatient Rehab
An OIG report found that the three largest Medicare Advantage insurers denied prior authorization requests for long-term acute care and inpatient rehabilitation at higher rates than other MA plans in ...
Premier Provides Recommendations on 2026 Interoperability and Prior Authorization Proposed Rule
Premier submitted comments to CMS, providing recommendations aimed at modernizing prior authorization and advancing interoperability across federal health programs.
Medicare Advantage Organizations Overturned Nearly All Appealed Prior Authorization Denials for Skilled Nursing Facility Admission, Raising Concerns About Initial Denials - Office of Inspector General (.gov)
Medicare Advantage Organizations Overturned Nearly All Appealed Prior Authorization Denials for Skilled Nursing Facility Admission, Raising Concerns About Initial Denials Office of Inspector General ...
How a CMS Proposed Rule Would Bridge the Divide Between EHRs and Payers on Electronic Prior Authorization
The following is a guest article by Tyler Wince, VP of Product & Technology for Specialty Solutions at DrFirst. This article is the next in the Healthcare Regulatory Talk series. Prior authorization ...
House committee takes step toward blocking Medicare AI prior authorization pilot
It’s another sign of lawmakers’ concern about the pilot, which has been lambasted for delaying care to seniors.
NACDS Urges CMS to Make Pharmacies Central to Modernizing Prior Authorization and Advancing Interoperability
In comments to the agency, NACDS calls for reforms that work within real-world pharmacy workflows — reducing the administrative burdens that delay patients' access to their medications. NACDS' consis...
What Upstream Prior Authorization Denials Mean for Home Health Providers
(June 16, 2026) MGMA Supports Proposed Rule Governing Electronic Prior Authorization for Drugs
(June 16, 2026) MGMA Supports Proposed Rule Governing Electronic Prior Authorization for Drugs Medical Group Management Association - MGMA