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Medical billing, coding, denials, credentialing, PCMH and practice operations, written to be useful on Monday morning.
The Insurer Prior Authorization Pledge, One Year In: What Actually Changed
A year after more than 50 health plans pledged to cut prior authorization, the industry reports an 11 percent reduction, UnitedHealthcare has promised much larger cuts, and the CMS rule now sets deadlines for government plans. Here is what changed in practice, what did not, and what to watch for January 1, 2027.
The Prior Authorization Metrics Payers Now Publish, and How to Use Them
Since January 1, 2026, Medicare Advantage, Medicaid managed care and Exchange plans must decide standard authorizations in seven days, give a specific denial reason, and publish annual authorization metrics. Where to find the reports, what they show, a worked comparison of two plans, and three ways to use them.
MedPAC's June 2026 Report: How Medicare Checks Your Claims, in Its Own Words
MedPAC's June 2026 Report to the Congress, released June 15, includes a plain description of how Medicare pays and polices claims: MAC edits, NCCI, CERT, RACs, the SMRC and prior authorization. Here is what the chapter says, the numbers in it, and what a practice should take from them.
How to Prepare for a Peer-to-Peer Review: Scripts, Evidence and Timing That Work
A peer-to-peer review is often the last chance to overturn a prior authorization denial before a formal appeal, and most practices walk in unprepared. Here is how to schedule it, what the physician should have on the desk, a five-minute script, and how to document the call so the outcome sticks.
AMA 2026 Annual Meeting: The New Prior Authorization Policy on AI Denials
At its Annual Meeting in Chicago, June 5 to 10, 2026, the AMA House of Delegates adopted policy pushing for AI-informed coverage denials to be reviewable by a licensed physician in the same specialty. Here is what was adopted, what it does and does not change, and how to use it in appeals today.
Revenue Cycle KPIs Explained for Physicians: Clean Claim Rate, Days in AR, More
Most practice owners get a monthly report full of revenue cycle KPIs and trust none of them. This glossary explains the ten that matter, gives the formula for each, the commonly quoted benchmark, the way each one gets gamed, and a worked example from a four-provider practice.
UnitedHealthcare June 2026 Bulletin: Five Lab Testing Policies Start September 1
UnitedHealthcare's June 2026 reimbursement bulletin, posted June 1, introduces five commercial lab testing policies effective September 1, 2026: allergen testing, hepatic fibrosis, chemotherapy assays, testosterone and vitamin B12. What each limits, the codes involved and what to check now.
UnitedHealthcare to Drop Prior Authorization for About 30 Percent of Services
On May 5, 2026 UnitedHealthcare said it will eliminate prior authorization for roughly 30 percent of the services that still require it, by the end of the year. Three weeks on, here is what the announcement does and does not say, what to check when the code lists post, and how to avoid the denials that follow.
Prior Authorization for Imaging: What Radiology Benefit Managers Check First
Most imaging prior authorization requests are decided by a radiology benefit manager, not the health plan, and the decision follows a fixed set of questions. We explain who EviCore, Carelon, Evolent and HealthHelp are, what they ask for a lumbar MRI, how to get a same-day approval and what changed in 2026.
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