Utilization & Network Management
Expert articles and analysis related to utilization & network management.
AI Summary — Last 7 Days
Prior authorization is becoming a more measurable—and therefore more contestable—lever in utilization and network management: new CMS-required public reporting shows insurers denied at least 1 in 8 standard PA requests across Medicare Advantage, Medicaid managed care, and federally facilitated ACA Marketplace plans, with rates varying widely by insurer, raising pressure on MA/MCO partners to justify utilization controls in value-based contracts (KFF analysis). At the same time, CMS is pushing FHIR-enabled electronic prior authorization and Epic is rolling out instant PA checks at Ochsner, Froedtert ThedaCare, Denver Health, and Summit Health, signaling a shift from retrospective complaints about administrative burden toward real-time, data-driven adjudication that could materially affect referral management, leakage, and care access workflows in ACOs and delegated-risk groups (Epic rollout). The strategic tension for VBC leaders is that payers will continue using PA as a cost and network-management tool, but CMS transparency requirements and interoperability mandates are making denial patterns visible enough to become contract negotiation points, compliance risks, and patient-access differentiators.
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...
CommonSpirit’s 5 targets for judging payer prior auth reform — and its Humana milestone
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CMS Proposes Changes to Incentivize FHIR-enabled Electronic Prior Authorization Use
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10 numbers that show prior authorization is still broken
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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