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CMS WISeR Model Brings Prior Authorization to Traditional Medicare in Six States
On June 27, 2025, the CMS Innovation Center announced the WISeR model, bringing prior authorization to a list of traditional Medicare services in six states from January 1, 2026. Here is what is covered, how the review works, and what practices in those states should do before January.
The June 23 Prior Authorization Pledge: What Changes in 2026 and 2027
On June 23, 2025, health insurers covering about 257 million Americans committed through AHIP and HHS to simplify prior authorization, with deadlines in 2026 and 2027. Here is what was promised, how it lines up with the CMS rule already on the books, and how to design your workflow now.
UnitedHealth's CEO Change and MA Scrutiny: What It Means for Your Practice
UnitedHealth Group replaced its chief executive on May 13, 2025, suspended its 2025 outlook and cited rising medical costs in Medicare Advantage, all amid press reports of Department of Justice investigations into MA billing. Here is what a large payer under pressure tends to do next, and how practices should prepare.
Clearinghouse Contingency Planning a Year After the Change Healthcare Attack
The February 2024 ransomware attack on Change Healthcare stopped claims, remittances and eligibility for weeks and exposed data on about 190 million people. A year on, here is what actually changed in how practices route transactions, what a real contingency plan contains, and how to test it before you need it.
A 5.06% Medicare Advantage Rate Increase for 2026: What It Means for Practices
CMS finalized a 5.06% average payment increase for Medicare Advantage plans in 2026 on April 7, 2025, well above the January estimate. Here is what drove the number, what the completed V28 risk model phase-in means for coding, and what practices with MA contracts should do before plans file bids in June.
HHS Restructuring, a New Secretary and the Medicaid Budget Fight: What to Watch
In ten weeks, HHS got a new Secretary, the House passed a budget resolution that points at Medicaid, and on March 27, 2025 HHS announced a plan to cut about 20,000 positions and fold 28 divisions into 15. Here is what happened, what it does and does not change for a practice, and what to watch.
How to Write a Medical Necessity Appeal That a Payer Reviewer Will Actually Read
A CO-50 denial is not the end of the claim; it is a request for an argument. Here is the structure we use for medical necessity appeals, the deadlines by payer type, the documents to attach, a worked example, and the mistakes that get well-supported services denied twice.
The AMA's New Prior Authorization Survey and the CMS-0057-F Clock
The AMA released its 2024 prior authorization physician survey on February 24, 2025: 93 percent of physicians report care delays and 29 percent report serious adverse events. Federal payer deadlines under CMS-0057-F start January 1, 2026. Here is what to build now.
Documenting Medical Necessity for Imaging Orders So the Claim Survives Review
Advanced imaging is denied for missing necessity more often than for missing authorization, and the order is usually where it fails. Here is what a reviewer looks for in the note, the ICD-10-CM specificity that matters, a before-and-after note, and a table of the elements by study type.
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