Utilization & Network Management
Expert articles and analysis related to utilization & network management.
AI Summary — Last 7 Days
CMS’s utilization-management agenda is moving on two fronts: tighter oversight of Medicare Advantage plan behavior and broader scrutiny of AI-enabled prior authorization, with WISeR drawing controversy even as CMS-0053-F continues to reshape payer-provider API and PA workflows. At the same time, MA network adequacy and payment integrity pressures intensified as Elevance faced both a $342M payment tied to a CMS billing probe and a separate challenge over MA Star Ratings methodology, while new evidence suggests cancer patients in MA may access fewer providers than Traditional Medicare beneficiaries—raising VBC questions about when “managed” care becomes under-access. For ACOs, health systems, and payer strategists, the pattern is clear: CMS under the Trump administration is keeping utilization and network management central to MA, Medicaid, and model design, but stakeholders should expect greater legal, operational, and reputational risk around prior authorization, AI tools, star ratings, and specialty access (KFF Health News; Healthcare Brew).
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