Criticism continues to mount against the Trump administration's plan to use AI-based prior authorization for Medicare claims. The Wasteful and Inappropriate Service Reduction (WISeR) model, now active in Arizona and five other states, has already generated reports of delayed care for seniors since its January launch. On Tuesday, a House...
As the Centers for Medicare and Medicaid Services (CMS) weighs the expansion of Medicare Advantage (MA) coverage through automatic enrollment, it's worth asking if the program is meeting the needs of U.S. seniors at a responsible cost to the American taxpayer. Providers say no, and are calling for Congressional action to solve some of...
Almost one year ago, 50 major health insurers met with U.S. health department leadership and pledged to rein in their use of prior authorization, which patients and providers complain severely disrupts the continuity of care. Now, despite industry studies demonstrating that the practice has been curbed by a little over 10%, the practice...National News
Industry leaders and health sector lobbies are lining up to support the Medicare Advantage Improvement Act (MAIA) of 2026, a bipartisan bill that addresses structural issues within Medicare Advantage.
The bill focuses on critical issues with billing and coverage like prior authorization, payment timing, and billing transparency. The...National News
The new standards are expected to be adopted by a group that includes Centene, Cigna, Humana, Aetna and UnitedHealthcare and will apply to orthopedic surgeries and imaging services like CTs and MRIs, in addition to other medical services that usually require prior authorization.
Modern Healthcare reports the standards will apply to...Arizona News
Under severe public scrutiny, health insurers have scaled back the use of prior authorization by 11% since 2024. Meanwhile, the new WISeR model faces struggles, but the Centers for Medicare and Medicaid Services (CMS) appears set on applying the practice to the Medicare program.
The Wasteful and Inappropriate Service Reduction Program...National News
A new proposed rule from the Centers for Medicare and Medicaid Services (CMS) targets prior authorization (PA) of pharmacy benefits by shortening the turnaround deadline for certain requests and requiring the disclosure of denial rates.
The regulation would require Medicaid and Children's Health Insurance Program (CHIP) insurers and...Arizona News
Prior authorization, or the insurance practice of requiring authorization prior to the delivery of care or dispensation of drugs, has been under fire for the consequences of restricting timely access to care. Now, payers will be required to post data on how often they deny requests, how quickly they process them and how often denials are...Arizona News
Nearly four months after CMS launched its Wasteful and Inappropriate Service Reduction, or WISeR, model, the Electronic Frontier Foundation filed a lawsuit March 25 seeking details on how the AI-enhanced prior authorization program works for Medicare fee-for-service beneficiaries. The model is now operating in Arizona and several other...Arizona News
Late last week, President Donald Trump signed an executive order that is intended to intervene against state-level regulations of artificial intelligence.
The executive order directs U.S. Attorney General Pam Bondi to establish an "AI Litigation Task Force," which would challenge state AI laws that are "inconsistent" with the...
A new report by HealthEdge, a healthcare technology company, looks at the biggest challenges for health payers and the strategies that plans are using to address them.
The report, The Great Rebalancing: Inside the New Realities Shaping Health Plan Performance reviews survey responses from health insurance leaders and identifies rising...
At its December 4 meeting, the Medicare Payment Advisory Committee (MedPAC) reviewed payment data on payment adequacy and potential payment updates and recommendations for its March 2026 report to Congress. This discussion included an update on post-acute care payments and an assessment of hospital performance.
MedPAC commissioners...Arizona News
House Democrats have introduced legislation that would block the Trump administration's plan to use AI to implement prior authorization in traditional Medicare. The Centers for Medicare and Medicaid Services (CMS) announced the Wasteful and Inappropriate Service Reduction (WISeR) model earlier this year for testing in six states,...White Papers, E books, Reports and more
Artificial intelligence (AI) is rapidly spreading through state Medicaid programs—mostly through the managed care organizations (MCOs) that administer them. A new Urban Institute report finds these tools are increasingly used for risk stratification, prior authorization, and care coordination, yet few states or health plans explain how...Arizona News
A new study shows that Medicare Advantage physician networks pale in comparison to traditional Medicare, but the Centers for Medicare and Medicaid Services (CMS) is pushing ahead with plans to make traditional Medicare look more like Medicare Advantage.
Medicare beneficiaries enrolled in both programs report that physician...National News
Earlier this month, the Medicare Payment Advisory Committee posted its presentation on the association between changes in Medicare Advantage enrollment and hospital finances.
The analysis, presented at the MedPAC September meeting, found that increases in Medicare Advantage enrollment are not associated with significant profit margin...
A new study on hospitalizations between 2017 and 2023 determined that Medicare Advantage beneficiaries are experiencing an increase in extended hospital stays following the COVID-19 pandemic.
The study, published in JAMA Internal Medicine, analyzed data from more than 89 million hospitalizations over a six-year period, including...
As the use of AI and large language models (LLMs) pervades all levels of healthcare, one major question is how the use of AI will impact the use of prior authorization by private insurers, and if the tech can be used to manufacture and justify coverage denials.
The American Medical Association developed a massive new policy with...National News
Medicare Advantage insurers are having a tough time. Humana was forced to refile its lawsuit against the Centers for Medicare and Medicaid Services (CMS) over inappropriate star ratings awards as it scales back its use of prior authorizations. Meanwhile, the American Hospital Association (AHA) testified in Congress about the problems...Arizona News
This week, the Centers for Medicare and Medicaid Services (CMS) Innovation Center (CMMI) announced a new model that will employ AI and machine learning to test ways to integrate prior authorization into traditional fee-for-service Medicare. The model will launch with providers in Arizona, Washington, New Jersey and Texas.
The model,...
