Utilization & Network Management
Expert articles and analysis related to utilization & network management.
AI Summary â Last 30 Days
CMS is tightening the transparency and infrastructure around utilization management: new required prior authorization reporting is exposing wide payer variationâdenial rates ranging from roughly 2% to 25% and at least 1 in 8 standard requests denied across MA, Medicaid managed care, and ACA marketplacesâwhile CMS is also proposing incentives for FHIR-enabled electronic prior authorization, pushing plans and providers toward more standardized, auditable workflows (KFF analysis; [Wilson Sonsini summary](https://news.google.com/rss/articles/CBMivgFBVV95cUxPZlFFSFFnZzk4X1NhN1hlUXJvdC05V2Q3Z3ROUXFJbHl3TjlXRVNweXJrVEFkNFk4MjBEWlZRaVVKeTM2bGVmeTJMMlVmMjg0WmF5bG5FdUNHdkFGWGI5QS1tSlc1WERrLThSX09ZU29FLU1OQmtCRDktLWp1YmtSc0xXNnRnWUpGOWVBUFU4WDI4cUpNM3Z2Vndra3FCYWV4SkxvMEpscnlf
Related Articles
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.
Prior Authorization Metrics Provide New Insights into Insurer Practices, but Gaps Remain
This analysis of available 2025 prior authorization data finds insurers denied at least 1 in 8 standard requests for prior authorization across three insurance markets: Medicare Advantage, Medicaid ma...
Prior Authorization In Medicare Advantage: Beneficiary Exposure And Plan Disenrollment In 2021
Prior Authorization In Medicare Advantage: Beneficiary Exposure And Plan Disenrollment In 2021Â Â Health Affairs
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
KFF: Insurers Denied 12%-18% of Prior Authorization Requests in 2025
KFF: Insurers Denied 12%-18% of Prior Authorization Requests in 2025Â Â MedCity News
CMS closes prior authorization transparency gaps AMA found in 15 health plans
CMS closes prior authorization transparency gaps AMA found in 15 health plans  Becker's ASC
On prior auth, CMS responds to AMA concerns - American Medical Association | AMA
On prior auth, CMS responds to AMA concerns  American Medical Association | AMA
Prior Authorization Metrics Provide New Insights into Insurer Practices, but Gaps Remain
From newsletter: This Week: Prior Authorization Metrics Provide New Insights into Insurer Practices This Week: Prior Authorization Metrics Provide New Insights into Insurer Practices, but Gaps Remai...
What CMSâ 2027 AI rule means for prior authorization (and maybe for fax machines)
new KFF analysis
From newsletter: Analysis Examines Denials of Prior Authorization Requests Across Markets and By Insurer Analysis Examines Denials of Prior Authorization Requests Across Markets and By Insurer Gaps ...