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,...National News
Nearly 50 health insurance companies signed onto a pledge with the federal government to streamline prior authorizations on Monday. The new practices will apply across all forms of private health insurance.
For years, private insurance companies have weathered criticism of the prior authorization process as providers and patients...Arizona News
As the 2025 Arizona Legislative Session winds down, Governor Katie Hobbs has signed and vetoed a slew of bills, many of which relate to Arizona healthcare.
On Monday and Tuesday, Governor Hobbs vetoed 48 bills sent to her desk by the Republican-controlled legislature. One such bill, proposed by Senator Wendy Rogers (R-Flagstaff) would...National News
Health Affairs pitched two reform strategies this week to limit the competitive advantage for Medicare Advantage (MA) plans that aggressively upcode - MedPAC estimated taxpayers overpaid MA plans by $50 billion in 2024. In other news this week, KFF found MA insurers made nearly 50 million prior authorization determinations in 2023...Arizona News
A new analysis looked at the rates of claims denials among ACA Marketplace plans in 2023 and found that nearly one in five in-network claims and 37% of out-of-network claims were denied.
The denial rate varied from plan to plan with some plans reaching in-network denials of 54% and some as low as 1%. The KFF analysis also showed that...Arizona News
In his first public remarks since the public murder of UnitedHealthcare (UHC) CEO Brian Thompson in December, UGH CEO Andrew Witty told investors during the fourth-quarter earnings call that the insurer is close to rolling out a new initiative to streamline prior authorizations.
Nearly all enrollees in Medicare Advantage are subject...National News
The public reaction following the public murder of UnitedHealthcare CEO Brian Thompson in Midtown Manhattan last week has set health executives across the country on edge. The murderer was arrested on Monday in Pennsylvania.
The shooter is Luigi Mangione, a 26-year-old from Maryland. He was arrested in Altoona, Pennsylvania and held...White Papers, E books, Reports and more
A new report by the National Association of Insurance Commissioners (NAIC) warns that advances in artificial intelligence (AI) use by insurers are outpacing state regulations.
The consumer representatives in NAIC are demanding "immediate regulatory action," Inside Health Policy reports. The report shows that insurers are using AI...
On Thursday, the Senate Homeland Security Permanent Subcommittee on Investigations (PSI) published a report on Medicare Advantage denials for post-acute care services. The study showed that the three largest Medicare Advantage insurers, UnitedHealthcare, Humana and CVS Aetna, significantly raised the rate of prior authorization denials...
UnitedHealthcare appears to have overcome financial issues related to the Change Healthcare cyberattack that took place earlier this year, but the company is lowering its expectations for 2025.
UnitedHealthcare's (UHC) third quarter (Q3) net income came in just over $6 billion or $6.51 per share, up from $5.84 for the same quarter in...
More insurers are planning to jump the Medicare Advantage ship, or at least scale back program participation in 2025.
It's anticipated that next year will bring fewer MA plans and supplemental benefit offerings following increased oversight by the Biden administration on overpayments to MA companies, which will lead to a projected...
The contradictions between the goals of Medicare Advantage plans and healthcare providers are becoming increasingly apparent, posing challenges equally for providers and payers.
Medicare Advantage places unique burdens on all provider types from hospitals to private practices. The central issue lies in the use of prior authorization,...
The Issue brief defines prior authorization and how this process used by Medicaid fee-for-service programs and managed care organizations (MCOs) requires approval before providing specific items, services, or medications.
Prior authorization (PA) aims to prevent unnecessary utilization, limit improper, fraudulent, and wasteful...
More than a dozen health systems nationwide have ended contracts with Medicare Advantage (MA) plans, citing excessive prior authorization and slow payments from insurers.
Mayo Clinic doesn't accept MA and more health systems are also saying 'no', including HealthPartners which announced its plans to leave UHC's MA network next year...
The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) announced last month that it would investigate the use of prior authorization in denials for post-acute care by Medicare Advantage plans.
In the new audit, OIG plans to look into processes for reviewing prior authorization requests for post-acute...
Patients, physicians, home health aides, advocacy groups, stakeholders and more all happily replied to a request for information (RFI) collecting feedback for the Centers for Medicare and Medicaid Services (CMS) on Medicare Advantage data policies and procedures. Turns out, MA isn't very popular among many stakeholders.
The RFI came...
Home care companies are pushing back on Medicare Advantage plans in negotiations for better pay rates and service.
Companies like Addus HomeCare, Interim Healthcare and others are refusing to accept some patients enrolled in Medicare Advantage plans due to low reimbursement rates and issues with prior authorization processes. They...
As legislative season advances, more than 40 states across the country are expected to consider bills that aim to speed up the delivery of care or place restrictions on the use of prior authorization by insurance plans.
In 2023, states enacted 20 bills that target prior authorization practices, but this year more than 70 measures have...
