Many health plans are discovering that even after digitizing medical policies and implementing FHIR APIs, prior authorization turnaround times remain slow and provider frustration remains high. The reason is straightforward: digitization alone does not make medical‑necessity determinations executable by automated systems at scale.

The post Digitizing Medical Policy Alone Will Not Automate Prior Authorization at Scale appeared first on MedCity News.

Rather than using AI to compete, we must design AI to collaborate. As the regulatory landscape evolves and industry pledges push for real-time, electronic, and transparent authorizations, the imperative is clear: technology must bridge the payer-provider divide, not widen it.

The post AI Is Fueling a New Arms Race in Healthcare: Here’s How We Stop It appeared first on MedCity News.

With regulatory scrutiny intensifying and the demand for speed, compliance, and clarity growing, understanding the nuanced differences between AI approaches is essential for payers, providers, and patients alike.

The post Choosing the Right Methods for the Right AI to Accelerate Prior Authorizations appeared first on MedCity News.

CMS and AHIP are raising the floor, but forward-thinking plans are aiming higher. They’re designing utilization management systems that are clinically sound, operationally efficient, and aligned with enterprise goals.

The post Why Health Plans Are Reclaiming Utilization Management, and What It Takes to Do It Right appeared first on MedCity News.

Guideline directed care pathways are a way to shift from transactional PA, where each service requires separate approval, to an episode-of-care model.

The post It’s Time to Rethink Prior Authorization for Chronic and Serious Conditions appeared first on MedCity News.

As an industry, we need to ask hard questions. Are delegated vendors delivering on the promise of better, faster, more transparent decisions? Or are they simply moving the pain to another part of the system?

The post The Delegation Dilemma: Why It’s Time for Health Plans to Rethink Vendor-Managed Utilization Management appeared first on MedCity News.

Without systemic redesign, these efforts risk reinforcing the same pain points that made prior authorization a flashpoint for payers and providers.

The post CMS and AHIP Isn’t the Finish Line: It’s the Starting Gun for Prior Auth Innovation appeared first on MedCity News.