If her post-surgical care is too restrictive, she lands in a setting that can’t support her recovery and her risk of readmission risk goes up. If her care is too permissive, she sits in a higher-cost setting she doesn’t clinically need. Neither outcome favors the member.

Since high-deductible plans are the norm in commercial coverage and daily cost-sharing is common in Medicare Advantage, members are shouldering more of the cost, no matter where they end up receiving care.

The right level of care is a clinical decision. It’s now a financial one for members, too. With an accurate first-pass determination, the member gets clinically appropriate care and isn’t paying for a setting she didn’t need, or being pushed to self-fund care she did.

When the First Determination Fails at Scale

New evidence from the Office of Inspector General (OIG) (published June 2026) found Medicare Advantage organizations (MAO) denied 65% of prior authorization requests for long-term care hospital (LTCH) stays and 54% of requests for inpatient rehabilitation facilities (IRFs) in June 2024.

When members and providers appealed, the pattern raised harder questions. MAOs overturned 36% of LTCH denials and 43% of IRF denials on appeal, with IRF overturn rates ranging from 14% to 86% across plans. A companion report on SNF admissions found MAOs overturned 95% of appealed denials in favor of the enrollee.

In one contractor-driven pattern documented by OIG, a single vendor processed roughly half of all SNF requests and denied at higher rates than plans reviewing internally. On appeal, 97% of that vendor’s denials were overturned.

America’s Health Insurance Plans (AHIP) noted the OIG data couldn’t distinguish clinical denials from denials tied to missing paperwork, out-of-network care, or excluded services. That distinction matters. It reinforces the underlying issue: the first-pass review must be comprehensive and apply criteria correctly, or the appeal process ends up doing the clinical work the initial review was supposed to do.

How Well-Run UM Puts Members in the Right Setting Before Discharge

The OIG findings describe what a determination process looks like when the clinical rigor and incentive structure behind it breaks down. A well-run utilization (UM) program does the opposite of what the data documents.

Prior authorization exists as a clinical quality tool. Applied well, it’s the mechanism that matches a member to the setting her clinical picture supports, before she’s discharged into the wrong one. An orthopedic member with strong home support and low fall risk may recover better at home with skilled nursing visits than in a facility. A member with limited mobility and complex comorbidities may need the intensive rehab a facility provides. At the end of the day, determinations need to reflect the clinical reality of each member.

But clinical determination is only as strong as the clinical judgment and independence behind it. An evidence-based review conducted by a same-specialty physician produces a decision that holds up, rather than one reversed on appeal after the member has already lost days or paid out of pocket. While technology can streamline intake and route cases efficiently, the determination itself belongs to a credentialed physician reviewer.

The framing matters. UM performed for cost containment produces the patterns OIG documented. UM built as clinical quality assurance produces the opposite: a first-pass decision that supports the member’s recovery and the treating physician’s plan of care.

Three Ways to Reach the Right Care, the First Time

1. Independent, incentive-free review. The reviewer making the determination should have no financial stake in the outcome. The contractor pattern OIG documented is instructive: reviewers whose incentives are tied to volume or denial rates make different decisions than reviewers whose only accountability is clinical accuracy. An independent review organization removes misalignment and evaluates the case on clinical merit.

2. Same-specialty, same-state physician matching. The right level of care for a post-surgical orthopedic member is a question best answered by a physician who practices in that specialty and ensures the determination leverages the standards applied in the member’s real-life clinical environment. Generalist review at scale produces the kind of variation OIG measured across MAOs — IRF overturn rates ranging from 14% to 86% aren’t random. They reflect who’s reviewing the case and how.

3. Evidence-based criteria applied consistently, with clinical accountability on every determination. Consistency is what keeps the first determination from becoming an appeal. Current, evidence-based criteria applied by a physician reviewer accountable for the decision produces a determination that holds up under scrutiny. Technology enables the workflow; the clinical decision stays with the clinician.

Getting the First Determination Right

The right level of care, determined correctly the first time, matters to members’ wallets. It matters even more to their health.

That’s the point of getting UM right, and it’s what the OIG data suggests too many post-acute reviews are getting wrong.

The post Why the First Level-of-Care Determination Matters More Than the Appeal appeared first on MRIoA.

Regulators have set firm dates. Under the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), affected payers have had to meet new decision timeframes and denial-reason requirements since Jan. 1, 2026. The required application programming interfaces (APIs), including the Prior Authorization API, must be live by Jan. 1, 2027.

Providers keep pointing to administrative burden, and the 2025 AMA prior authorization survey puts numbers on it: 40 requests per physician each week, 13 hours of physician and staff time, and 95% saying it delays care. Patients, meanwhile, now have generative AI tools that can write a coherent appeal in minutes.

Payers are responding by moving faster. That instinct makes sense. It also raises a harder question: faster than what, and at what cost?

MRIoA sits in the middle of this. As an independent clinical review organization, we review on behalf of health plans, we hear from providers, and we see appeals arrive with AI-assisted arguments attached. That vantage point shapes how we think about where AI belongs.

Trust replaced capability as the constraint

For most of the past decade, the limit on AI in healthcare was capability. The tools could not read a clinical record well enough to be useful.

But the deeper problem was never the tools. As MRIoA Chief Technology Officer Nilesh Shah put it during a recent webinar with Itiliti Health, the industry digitized the transport, meaning how documents move, without digitizing the content. A faxed PDF became an uploaded PDF. The document moved faster, but nobody updated the structure of what was inside it. Three decades of partial digitization left the industry delivering unstructured data electronically, on both the provider and payer sides.

Then generative AI closed that gap as it became capable of reading unstructured clinical text. The capability constraint disappeared, and a trust and accountability constraint replaced it. For years the technology curve and the trust curve had moved in opposite directions. That is why, as Shah described it, the line between using AI to speed up work and letting it make the determination is now a compliance question rather than a philosophical one.

The question underneath all of it is short. “Can you trust the work being done?” It applies no matter who did the work, whether a model, your own staff, a vendor, or a platform.

The consequences show up on appeal. On the patient side, the barrier to a strong appeal was never information. Plan documents and appeal rights have been public for years. The barrier was effort and expertise, and generative AI removed it. Appeal quality no longer tracks a member’s sophistication or ability to pay for help. Appeals are getting stronger. Determinations that are fast but cannot be explained are the ones getting overturned.

Chad Frank, Chief Innovation Officer at Itiliti Health, framed the response as four categories: accountability, transparency, clinical authority, and traceability. Shah agreed with the list and organized MRIoA’s approach along a different axis: three layers, each with its own questions and governing framework.

Layer 1: Infrastructure

The first layer is the technology itself. Can it be kept secure? Can it be governed? Does it meet regulatory requirements? These are familiar questions, and most health plans already have mature answers for every other system they run.

Nothing about AI changes what you ask at this layer. There is simply more of it to ask about. MRIoA aligns this layer to the NIST AI Risk Management Framework, which exists so organizations do not have to invent infrastructure-level AI controls from scratch.

Layer 2: The processing platform

The second layer is where the work happens, on the platforms reviewers use every day. Here the questions shift. Can the data be protected? Are HIPAA protections in force? Can the platform itself be governed for appropriate AI use, so that a tool built to summarize a record is not quietly doing something else?

MRIoA aligns this layer to HITRUST’s AI security requirements, which extend an existing information security framework rather than running alongside it as a separate program.

Layer 3: Clinical determination

The third layer is the determination itself, and it is where MRIoA draws its firmest line.

“We do not use any tools to make clinical decisions,” Shah said. “Licensed clinicians remain responsible for every determination and every clinical rationale.”

AI’s role at MRIoA is deliberately narrow. It helps gather and validate information, summarizes clinical records, and produces consistent, member-friendly documentation. It supports clinicians rather than substituting for them. A network of more than 700 clinicians across more than 150 specialties is only an advantage if those clinicians are the ones making decisions. MRIoA is aligning this layer to URAC’s Health Care AI Accreditation.

Separating the layers works because each one asks its own question. Security controls answer whether the technology can be trusted. Clinician attestation answers who is responsible for the decision. Each framework is strong where it applies, and the three of them together cover ground that one policy written to span all three rarely does.

What it takes to hold the line

An attendee asked during the webinar: how can anyone tell whether an appeal was written by AI? Shah’s answer was honest. Largely, you cannot. Machine-readable watermarking is being explored, but the industry cannot rely on it today.

So the answer is not detection. It is governance on your own side of the process. At MRIoA, AI use is covered in reviewer training, reviewers attest that the final output is always human-generated, and quality reviews confirm that the attestation holds. Payer clients are increasingly writing the same requirement into their contracts.

Frank offered a useful test for whether a workflow can withstand that scrutiny: it should be traceable, explainable, and repeatable. That is the practical difference between a deterministic process, meaning one you can trace and prove, and a probabilistic one, which amounts to a well-informed guess. If a workflow cannot be described the first way, AI is not the problem.

Some limits are a choice, not a requirement. Speaking about clinical judgment, Shah said: “There’s a human aspect to it that I don’t know if AI can ever get to, and we really don’t want them to get to that level.”

Why this matters now

The window for setting these standards voluntarily is narrowing. As Shah noted, states keep legislating without coordinating with one another.

At least seven states passed AI prior authorization laws in 2026 alone. Several now bar AI as the sole basis for an adverse determination without licensed human review, several require plans to disclose where AI is used, and several add audit trail and reporting requirements. Those requirements map onto the third layer almost exactly. They are already law in some states and not in others.

Health plans that define their own guardrails now will keep control of how AI is used in their operations. Plans that wait will inherit someone else’s definition.

Hear the full conversation

Clarity and confidence in every clinical decision do not happen by accident. They come from knowing where technology helps, where a clinician decides, and how you would prove it.

In the full webinar, Nilesh Shah and Chad Frank work through the “bot wars” arms race, why layering AI on top of unchanged processes creates more work instead of less, and what these three layers look like in practice.

Watch the full webinar: AI in Prior Auth: Efficiency, Guardrails, and What Bot Wars Mean for Payers

The post Three Layers of Trust for AI in Prior Authorization appeared first on MRIoA.

Listen in as Nilesh Shah, Chief Technology Officer at MRIoA, and Chad Frank, Chief Innovation Officer at Itiliti Health, discuss how healthcare organizations can apply responsible AI practices, avoid the “bot wars” escalating between payers and providers, and establish guardrails that support clinician decision-making rather than replace it.

Key learning objectives:

• Understand how AI is being deployed responsibly in PA workflows today and what efficiency looks like in practice.
• Identify the guardrails payers need before AI-driven PA scales, including human clinical review on all denials.
• Assess the emerging threat of patient-side and provider-side AI tools designed to fight denials, and what it means for payer strategy.
• Learn why the industry must self-regulate now, before government mandates create fragmented, unworkable standards.

Watch the full webinar recording to understand how MRIoA’s governance frameworks — grounded in NIST, HITRUST AI, and URAC accreditation standards — position organizations to deliver clarity and confidence in every clinical decision.

View Now

The post AI in Prior Auth: Efficiency, Guardrails, and What Bot Wars Mean for Payers appeared first on MRIoA.

However, many programs struggle to deliver on that design. More than 1 in 3 physicians report that prior authorization (PA) criteria are rarely or never evidence-based and only 16% of physicians who take part in peer-to-peer reviews say the health plan clinician was appropriately qualified. The concept isn’t broken, but for many programs the execution isn’t matching the intent.

What Peer-to-Peer Review Is For

When the initial UM review applies criteria to available documentation, the peer-to-peer conversation adds clinical context that documentation alone can’t capture, such as why a member needs this dosage, reasons an alternative won’t work, or what’s already been tried.

Done well, peer-to-peer review is a clinical safety net. When two physicians can discuss the nuances of a member’s case and clinical evidence, inappropriate adverse determinations go down, and treating physicians have confidence that the process was substantive, not just procedural.

Done poorly, peer-to-peer is a scheduling hurdle that ends in a five-minute call with a generalist reviewer who can’t meaningfully evaluate the case. This version doesn’t reduce inappropriate determinations. It generates them.

Building a Peer-to-Peer Program That Works

The fix starts with two things: who’s doing the review and how quickly it happens.

Specialty-matched review means the physician on the plan’s side has current, relevant clinical expertise in the condition and treatment under review. When a pediatric neurologist calls about a complex seizure management case, the reviewer should be a pediatric neurologist, not a family medicine physician. That match is what makes the conversation genuinely peer-to-peer, and it’s what produces accurate determinations. 

This is no longer just a best practice. A growing number of states, including Alaska, Nebraska, Illinois, New York, and Texas, now require same-specialty or same-or-similar-specialty reviewers for medical necessity determinations, and a bipartisan federal bill reintroduced in 2025 would extend that standard to Medicare, Medicare Advantage, and Part D plans. Specialty mismatch is turning from a quality gap into regulatory exposure. 

It also fills a gap that’s easy to underestimate: the blind spots that inevitably creep into any physician’s knowledge base. Based on the pace of medical innovation, it’s nearly impossible for every clinician to stay current across every treatment protocol. A specialty-matched reviewer brings that current evidence into the conversation, keeping the treating physician informed on developments in treatment procedures and clinical guidelines relevant to the case. 

When blind spots go unchecked, the consequences are specific: inaccurate diagnoses, ineffective treatments, exposure to unnecessary treatments, and unnecessary out-of-pocket costs for members and their families. A specialty-matched reviewer protects members from unnecessary or potentially harmful care by giving the treating physician the current evidence and clinical context needed to get the approach right. When the determination is right the first time, the member, provider, and plan all benefit.

For example, in a recent blog our team highlighted how pediatric psychiatric cases are uniquely complex. A 15-year-old with severe depression may also carry a trauma history, a learning disability, and a home environment that is destabilizing. Comorbidity is the norm in this population and untangling it requires a specialist reviewer who understands how these conditions interact developmentally. If this case required a peer-to-peer review, a pediatric subspecialist would be appropriate. 

Turnaround time matters because a peer-to-peer review that takes three days to schedule is one that may not happen. The treating physician’s focus shifts to other urgent cases, the member waits, and the determination gets made without the conversation to inform it.

For health plans evaluating their peer-to-peer program — whether building internally or working with a review partner — a few criteria separate programs that work from programs that don’t.

1. The process of specialty matching: A large reviewer panel is only useful if the matching methodology connects the right case to the right reviewer consistently.
2. TAT reporting against real SLAs, not averages: Average turnaround can mask significant variation. Ask for distribution data on what percentage of cases meet the contracted timeline, and what happens to the ones that don’t.
3. Confirmed accreditation: URAC dual accreditation (Health Utilization Management and Independent Review Organization) and NCQA certification are baseline indicators that the program meets national standards for clinical review quality.
4. The escalation pathway: When a peer-to-peer conversation doesn’t resolve the case, what happens next? A defined, transparent process for escalation protects both the member and the plan. A growing number of states now require plans to publish their prior authorization requirements and timelines online, so ask whether a partner’s escalation path is documented and available to providers before a case ever reaches peer-to-peer.
5. How technology is used: The right technology can accelerate scheduling, documentation, and case routing, but it never replaces clinical judgment. 

The Conversation That Pays for Itself

Health plans that get peer-to-peer right do more than treat it as a regulatory checkbox. They treat peer-to-peer reviews as the highest-value conversation in their UM process — the one that protects members, earns physician trust, and gets the clinical decision right before it becomes an appeal. The plans that invest in specialty-matched review and hold their programs to real turnaround and quality standards ultimately see the difference on both sides of the ledger.

The post Getting Peer-to-Peer Reviews Right appeared first on MRIoA.

Medical Review Institute of America (MRIoA) is proud to announce its designation as the inaugural Community Impact Partner of the Texas Association of Community Health Plans (TACHP).
This partnership reflects a shared commitment to advancing community-based healthcare in Texas by fostering stronger connections between community health plans and mission-aligned organizations dedicated to improving health outcomes for Texas Medicaid members and the communities they serve.

As TACHP’s first Community Impact Partner, MRIoA looks forward to collaborating with health plan leaders across the state to support innovation, encourage knowledge-sharing, and help address some of healthcare’s most pressing challenges through education, collaboration, and shared problem-solving.

“We are honored to serve as TACHP’s inaugural Community Impact Partner,” said Chris Brandl, Senior Director of Growth at MRIoA “Community health plans play a critical role in delivering accessible, high-quality care to Texans. We are excited to support TACHP’s efforts to bring together organizations that share a commitment to improving health outcomes and strengthening the communities they serve.”

Through the Community Impact Partnership, MRIoA will support TACHP’s mission to:

• Strengthen partnerships between community health plans and mission-aligned organizations offering innovative solutions that support Texas Medicaid members and communities.
• Create opportunities for collaboration, education, and shared problem-solving on key healthcare challenges.

“We’re proud to welcome MRIoA as TACHP’s inaugural Community Impact Partner,” said Janet Walker, President and CEO of the Texas Association of Community Health Plans. “This partnership represents the kind of collaboration that helps drive new ideas, shared learning, and meaningful progress for the more than 1.7 million Texans served by our member health plans. We look forward to working together to support healthier communities across Texas.”

Together, MRIoA and TACHP look forward to building meaningful relationships, fostering productive dialogue, and supporting initiatives that help improve the health and well-being of communities throughout Texas.

About TACHP
The Texas Association of Community Health Plans (TACHP) represents community-based health plans that provide access to quality healthcare for communities across Texas. Through advocacy, collaboration, and innovation, TACHP supports its members in advancing healthcare quality, access, operational readiness, and long-term community impact. For more information, visit www.tachp.org

About MRIoA
Founded in 1983, Medical Review Institute of America, LLC (MRIoA) is a leading clinical review company in the United States. With one of the largest and most extensive clinical review networks, industry-leading turnaround times, and utilization review licensing in all states that require it, MRIoA’s professionalism, enthusiasm, and collaborative approach are transforming clinical care delivery nationwide. MRIoA is a technology-enabled provider of clinical insights to payers and patients through analytics and evidence-based clinical opinions derived from independent specialty reviews and virtual second opinion solutions that empower better decision-making.

The post MRIoA Named Inaugural Community Impact Partner of TACHP, Advancing Collaboration for Texas Communities appeared first on MRIoA.

There are several cost drivers that need attention. One lever for cost management is utilization management, which can responsibly remove unnecessary cost: care in an inappropriate setting, treatment the evidence does not support, and determinations that do not hold up and return as appeals. Two shifts make that possible.

1. The reviewer is qualified for the case. The recent AMA survey found that only 16 percent of physicians say the health plan representative in a peer-to-peer review is often or always appropriately qualified. A determination made by a clinician matched to the specialty and the clinical question is more accurate, more defensible, and less likely to be overturned, which is precisely the outcome now visible in public metrics. Work with a UM partner whose model is built with a broad network of actively practicing, same-specialty physician reviewers licensed in all 50 states, so the person reviewing the case actually practices in the field.
2. Focus on where care is delivered, not just whether it is approved. Recent reporting on hospital market consolidation found the same procedure priced at more than double from one facility to another in the same region, driven by market power rather than any clinical difference. Approving a medically necessary service is only half the decision; the setting can change its cost by a wide margin. Review that surfaces appropriate, lower-cost sites of care captures spend that a simple approve-or-redirect decision never reaches.

What better UM looks like in practice

For plans trying to manage medical trend without adding review burden, four moves matter most.

• Concentrate review where cost and variability are highest. Pull low-value, low-yield requests off the prior authorization list and focus clinical attention on high-cost, high-variability services. This aligns with the federal reductions rather than fighting them.
• Modernize the workflow, keep the physician in the decision. Tech-enabled intake and routing shorten turnaround and help meet CMS-0057-F timeframes of 72 hours for expedited and seven calendar days for standard requests, while physician reviewers make every determination. Technology enables the process; clinicians make the call.
• Treat determination quality as the number that matters. Same-specialty, physician-led review produces more accurate, more defensible decisions, reducing the appeals and rework that erase any short-term savings, and standing up to public reporting.
• Use your own review data. Benchmarking and analytics across review activity surface the root causes of unnecessary prior authorization and spend, turning individual determinations into operational improvement.

Utilization management is no longer a private cost lever a plan can turn up quietly. It is a published, comparable measure of clinical judgment. The plans that lower cost from here will be the ones whose reviews are appropriate, defensible, and delivered by the right clinician, because that is now the same thing as the cost strategy that survives public scrutiny. That is the standard MRIoA was built to meet: clarity and confidence in every clinical decision.

The principles behind better utilization management extend across every part of a health plan’s book of business. Specialty pharmacy is one of the highest-stakes areas: as drug costs continue to climb, the quality of the clinical review behind each determination matters as much as the decision itself. Safeguarding Care by Rethinking Utilization Management for High-Cost Specialty Drugs examines what rigorous, independent specialty drug UM actually looks like in practice. And because the regulatory environment shapes what plans are required to do, not just what they choose to do, Compliance Is a Business Risk You Can’t Ignore outlines how state and federal PA reform is raising the stakes for every clinical operations team.

To see how physician-led review ensures members receive appropriate care, schedule a consultation with our clinical team at mrioa.com.

The post The Importance of Utilization Management Just Increased appeared first on MRIoA.

Watch MRIoA’s Fall 2026 Regulatory Roundtable for a practical look at what’s coming and how to assess whether your organization is ready. The session is built for compliance, clinical, operational, and utilization management leaders who need to turn regulatory change into operational decisions.

What You’ll Gain:

• A clear view of the 2027 implementation landscape and the common themes running through this year’s state legislation
• How new requirements may affect review standards, AI-supported review, prior authorization reporting and publication obligations, and electronic prior authorization readiness
• Practical considerations for assessing policy, process, delegation, technology, and documentation readiness

States on the Radar:

Alaska, California, Colorado, Delaware, Georgia, Illinois, Iowa, Kentucky, Louisiana, Minnesota, New Hampshire, New Mexico, New York, Oregon, Virginia, and Washington.

Why It Matters:

State requirements rarely arrive all at once, and they rarely line up neatly. Plans operating across multiple states will need to reconcile different definitions, timelines, and reporting obligations inside the same workflows. Organizations that start assessing readiness in 2026 have room to adjust policies, retrain teams, and validate documentation before the requirements take effect. Organizations that wait will be doing the same work against a deadline.

Led by Aja Leichliter, Vice President and Chief Compliance Officer at MRIoA, this session draws on more than 20 years of experience across state utilization review and independent review organization mandates, URAC and NCQA standards, and federal prior authorization rules.

The post Fall 2026 Regulatory Roundtable appeared first on MRIoA.

UM Touches Nearly Every Care Decision, Yet It’s Widely Misunderstood

Utilization management shapes nearly every significant care decision made in U.S. healthcare, yet it remains one of the least understood functions in the system, often reduced in shorthand to “the prior auth department.” That framing was already too narrow when the Institute of Medicine (IOM) first studied the field in 1989, and it’s even less accurate now.

Two forces make this the moment to understand UM more precisely. New CMS operational requirements take effect January 1, 2026, under the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F). And physician sentiment has become impossible to ignore: in the 2025 AMA Prior Authorization Physician Survey, 95% of physicians say prior authorization processes delay access to necessary care.

UM began as a cost-containment tool. The programs that hold up under regulatory and clinical scrutiny today are the ones that have evolved into a clinical quality discipline instead.

What Is Utilization Management?

The field’s standard definition comes from the Institute of Medicine’s 1989 report: techniques used by, or on behalf of, purchasers of health benefits to manage costs by influencing care decisions through case-by-case assessment of appropriateness.

In practice, that plays out across three review windows: prospective review (prior authorization), concurrent review, and retrospective review, backed by peer review, appeals, and independent or external review as the system’s checks on any single determination. Prior authorization is one component of UM, working as a clinical quality tool applied before care is delivered, not a standalone product or a cost-cutting mechanism on its own.

Where Did Utilization Management Come From?

UM’s roots trace to the mid-1960s and 1970s, when Medicare and Medicaid created formal utilization review processes, and Congress established Professional Standards Review Organizations in 1972 to evaluate medical necessity with peer-review boards of care delivered through federal healthcare programs. Through the 1980s, employers and insurers adopted utilization review widely as health costs climbed, and UM grew into a private-sector industry.

The IOM’s 1989 report gave the field a definition, legitimacy, and its first serious quality critique. The managed care backlash of the 1990s followed, and accreditation bodies including URAC and the National Committee for Quality Assurance (NCQA), emerged to standardize review quality and independence. Evidence-based clinical criteria matured through the 2000s and 2010s as external review rights expanded under state law and the Affordable Care Act. The 2020s have brought a wave of regulatory modernization: electronic prior authorization, mandated turnaround times, transparency reporting, and state-level reform, culminating in CMS-0057-F.

What Makes a Utilization Management Program High-Quality?

Not all UM programs are built the same, and the gap between a strong program and a weak one shows up in five places.

Evidence-based criteria, applied consistently. Determinations should be grounded in current clinical literature, not blanket rules applied without regard to the individual case. URAC’s accreditation standards build consistency and evidence-based practice into the review process itself.

The right reviewer for the case. Quality review means same-specialty physician review, and, where required, review by a physician licensed in the same state as the patient, per URAC’s standards.

Speed as a quality metric, not just an operational one. Turnaround time is now a compliance requirement. The guidelines under CMS-0057-F set a 72-hour standard for expedited requests and 7 calendar days for standard requests.

Independence and conflict-of-interest safeguards. No incentive should be tied to determination outcomes. That independence is the premise behind the independent review organization model and behind URAC’s dual accreditation structure.

Transparency in the decision and the path to challenge it. Every determination needs a specific, transparent reason and a meaningful appeals path, with peer-to-peer dialogue available in place of one-way adjudication. CMS-0057-F formalizes several of these requirements for impacted payers.

What’s Changing in Utilization Management?

The operational provisions of CMS-0057-F took effect January 1, 2026: standardized decision timeframes, specific reasons required for adverse determinations, and public prior authorization metrics, with impacted payers’ first reports due March 31, 2026. Fast Healthcare Interoperability Resources (FHIR) API requirements and more are required by January 1, 2027.

States haven’t waited for federal action. A wave of states enacted prior authorization reform in 2024 and 2025, with more than a dozen in 2024 alone, and requirements now vary meaningfully by state on gold-carding, decision timelines, and transparency. Health plan leadership evaluating a UM partner should confirm the current state count against the AMA’s tracker before assuming uniform requirements across their footprint.

The industry has also made its own commitments. In June 2025, over 60 health insurers pledged to reforms including ensuring clinical denials get reviewed by a qualified clinician and expanding real-time responses. Physicians remain skeptical it will hold: the same 2025 AMA survey found only one in three physicians believe the pledge will make a meaningful difference, and just one in four believe medical-necessity denials are consistently reviewed by an appropriately qualified clinician today. Both data points are worth holding in mind at once: the commitments are real, and so is the skepticism about whether they’ll be honored in practice.

Technology’s role in UM is also shifting, though not in the direction some assume. The programs earning trust are using intake automation, criteria surfacing, and analytics to reduce unnecessary prior authorization volume, not to make determinations. Every one of those tech-enabled workflows still routes the actual decision to a physician reviewer.

For a health plan or TPA evaluating a UM partner in 2026, confirm these five criteria—regardless of state or line of business:

• Evidence-based criteria, applied consistently
• Specialty-matched physician review
• Accreditation through URAC or NCQA
• Measured and reported turnaround time
• Peer-to-peer dialogue available
• Analytics designed to reduce review volume, not increase throughput

How MRIoA Approaches Clinical Review

Medical Review Institute of America (MRIoA) has operated as a clinically driven utilization management partner since 1983. That 40-plus year track record is backed by URAC dual accreditation across Health Utilization Management and Independent Review Organization, plus NCQA accreditation, a network of 700-plus state-matched specialists across 150-plus specialties, and licensure in all 50 states.

Every case is matched to a same-specialty physician reviewer, with MRIoA’s technology streamlining intake and workflow so that reviewers can focus on the clinical judgment only they can provide. On MRIoA’s own reviews, that structure supports 98%+ turnaround-time performance, 99%+ quality performance, and more than 2.4 million reviews completed per year.

UM’s 40-year history is really the industry learning, sometimes the hard way, that cost and quality aren’t competing goals when reviews are clinically led. Health plans and at-risk providers evaluating a UM partner can talk with MRIoA’s clinical review team about benchmarking their UM program against the standard outlined above.

Talk with MRIoA’s clinical review team about your UM program. Click here to learn more.

Frequently Asked Questions

What is utilization management in healthcare?

Utilization management is the set of clinical review processes payers use to confirm that requested care is medically necessary and appropriate. It includes prospective review (prior authorization), concurrent review, and retrospective review, anchored to the IOM’s 1989 definition of the field.

What are the three types of utilization review?

Prospective review happens before care is delivered and includes prior authorization. Concurrent review happens during an ongoing course of care, such as an inpatient stay. Retrospective review happens after care has been delivered, evaluating appropriateness after the fact.

Is prior authorization the same as utilization management?

No. Prior authorization is one prospective component of UM, not the whole discipline. UM also includes concurrent and retrospective review, plus peer review, appeals, and independent or external review.

What does “medical necessity” mean in a clinical review?

A determination that a requested service is appropriate for the patient’s condition based on current clinical evidence, assessed case by case rather than through a blanket rule. Quality reviews apply this standard through same-specialty physician judgment, not automated criteria alone.

What makes a utilization management program high-quality?

Evidence-based criteria applied consistently, specialty-matched physician review, independence from outcome-based incentives, measured turnaround time, and transparency in both the determination and the appeals path.

What are the CMS prior authorization requirements for 2026?

Under CMS-0057-F, impacted payers must decide expedited requests within 72 hours and standard requests within 7 calendar days, provide specific reasons for adverse determinations, and publicly report prior authorization metrics, with first reports due March 31, 2026.

The post The Evolution of Utilization Management: From Cost Containment to Clinical Quality appeared first on MRIoA.

Public reporting requirements reveal what happens without that discipline. A January 2026 KFF analysis found that Medicare Advantage insurers made nearly 53 million prior authorization determinations in 2024, and 80.7% of appealed denials were partially or fully overturned, a pattern consistent since 2019. A June 2026 HHS OIG report found 95% of appealed skilled nursing facility denials overturned, language OIG itself used to say this “raises concerns” about the initial determinations.

Review quality is the variable that determines whether UM functions as a clinical quality tool or a source of rework, provider abrasion, and regulatory exposure.

What Quality Actually Means in a Clinical Review

“Quality” gets used loosely in UM. Measured precisely, it comes down to four dimensions: the right reviewer, current evidence, first-pass accuracy, and defensible documentation.

The reviewer-match gap is where the industry’s own data is most uncomfortable. In the 2025 AMA Prior Authorization Physician Survey, only 24% of physicians say medical-necessity denials are consistently reviewed by a licensed, qualified clinician, and just 16% say the health plan representative in a peer-to-peer review often or always has the appropriate credentials. The full survey data breaks this down further by specialty and line of business.

First-pass accuracy is what overturn rates, reviewer consistency, and audit scores are actually measuring, and it’s built into accreditation for a reason: URAC’s utilization review standards set the timeframe and process expectations that a defensible review has to meet. Worth noting for a full picture, not just a favorable one: KFF’s own analysis points out that high overturn rates can also reflect incomplete documentation at the initial request, not only reviewer error. That’s a reason complete information capture belongs inside the definition of quality, not outside it.

What Members Gain When the Review Is Right the First Time

An overturned appeal represents care a provider already ordered and a plan later agreed was necessary, just delayed by the extra step of appealing it, as KFF frames it. That delay isn’t neutral. In the 2025 AMA survey, more than 1 in 4 physicians reported that prior authorization led to a serious adverse event for a patient in their care.

Quality protects members in both directions at once: confirming that requested care is evidence-based and appropriate, which is what prior authorization is designed to do as a clinical quality tool, and confirming that appropriate care isn’t needlessly delayed by a review that gets it wrong the first time. Getting both of those directions right, consistently, is what a health plan owes the members whose care depends on the decision.

What Providers Gain: A Peer Worth Talking To

Provider abrasion around prior authorization usually gets treated as a network relations problem. It’s more accurately a quality symptom. Physicians report completing 40 prior authorizations per week on average, and 94% say PA contributes to burnout, according to the AMA. Underneath the volume, the skepticism is specifically about who’s on the other end of the review.

Specialty matching is the structural fix. When peer-to-peer review means a same-specialty physician talking to another physician, the conversation functions as clinical dialogue instead of an obstacle to route around, and a determination that redirects care to a more appropriate option keeps its credibility with the ordering provider. Fewer resubmissions and escalations follow from that one upstream decision: who reviews the case in the first place.

The Economics: You Pay for Review Quality Either Way

A low-quality determination gets paid for three times:

• Once in the original review
• Again in the appeal it triggers
• Third time in downstream exposure

For CMS-0057-F payers, public reporting makes the first two visible to regulators, providers, and members directly; plans outside that scope don’t face public disclosure, but the underlying costs still show up in appeal volume and provider relationships. The third is easy to overlook in a procurement decision built around unit price: KFF’s analysis of post-acute care denials notes that independent review entity reversals can negatively affect a plan’s star ratings.

A quality evaluation looks at what predicts first-pass accuracy before a single case is reviewed:

• URAC or NCQA accreditation
• Depth of a specialty-matched physician panel, all-state licensure
• Documented, audited quality program the partner is willing to show you

How MRIoA Builds Quality Into Every Review

MRIoA has operated as a clinically driven utilization management partner for more than 40 years, built specifically around the reviewer-match and first-pass-accuracy dimensions of quality described in this article. That track record is backed by URAC dual accreditation across Health Utilization Management and Independent Review Organization, NCQA accreditation, HITRUST certification, a network of 700-plus state-matched physician specialists across 150-plus specialties, and licensure in all 50 states.

MRIoA’s tech-enabled workflows streamline intake and case routing, with every determination made by a physician reviewer matched to the case. That structure supports 99%+ quality and 98%+ turnaround-time performance across more than 2.4 million reviews per year, the kind of first-pass accuracy that keeps a plan off the overturn-rate scoreboard rather than on it.

A Midwest Blue Cross Blue Shield plan partnered with MRIoA to eliminate a sizeable medical director review backlog while sustaining more than 98% quality and turnaround-time performance throughout. Health plans, TPAs, and PBMs evaluating a UM partner’s quality program are welcome to schedule a consultation with MRIoA’s clinical review team to benchmark their program’s quality metrics against that standard.

The post Quality in Clinical Review: The UM Metric That Pays for Itself appeared first on MRIoA.

A 14-year-old with high-functioning autism spectrum disorder (ASD) is denied 15 hours.

Both determinations could be wrong.

Medical directors understand this juxtaposition: autism-related utilization management (UM) is a lose-lose if you get it wrong in either direction. Deny too aggressively and you’re exposed to parity complaints, member grievances, and litigation. Approve everything without clinical scrutiny and you’re failing members who need the right services, not just more services. At the end of the day, neither outcome serves the member.

A practical path between these two failure modes exists, but it requires clinical precision at the review level, not policy reflexes applied at scale.

Why Autism UM Is Uniquely Hard to Calibrate

The challenge starts with the condition itself. The 4-year-old and the 14-year-old in our example above require different clinical reasoning, different intensity benchmarks, and different outcome measures — but both can land in the same review queue and be treated as variations of the same request. Autism is genuinely heterogeneous, and that heterogeneity is what makes this category of UM uniquely hard to calibrate.

Recent estimates from the CDC’s Autism and Developmental Disabilities Monitoring Network estimated ASD prevalence among 8-year-olds at 1 in 31 — and that number continues to increase, which means case volume is increasing with it.

Evidence-based intensity benchmarks exist, but they’re not settled. The Council of Autism Service Providers (CASP) standards of care call for 30 to 40 hours per week of direct ABA intervention for young children, sustained for at least two years. Yet the research on optimal dosage, age of intervention, and concurrent service combinations has been critiqued enough that the council published a white paper in 2025 specifically to counteract studies contesting its position on intensity.

That complexity runs deeper than hours per week. ABA is commonly misperceived as one practice when it’s actually a set of different intervention practices, and the appropriate combination varies by patient. UM criteria built for more uniform conditions don’t account for that variability well. Applied without clinical context, they produce false positives (approving low-value services) and false negatives (reducing necessary treatment) in roughly equal measure.

State autism mandates create an additional layer of complexity. Mandate language often sets floors on coverage but says little about clinical standards for appropriateness review. That gap leaves medical directors to calibrate on their own.

The Overutilization Side of the Equation

Any honest conversation about autism UM must acknowledge that inappropriate approvals are also harmful. A child receiving 40 hours of ABA per week when 20 would produce equivalent outcomes is not getting better care. The excess hours carry opportunity costs for the family, and they consume resources that could reach other members waiting for services.

The spending trajectory makes this concrete. North Carolina’s Medicaid payments for ABA went from $122 million in fiscal year 2022 to a projected $639 million in fiscal year 2026 — a 423% increase in four years. That growth is driven partly by rising prevalence and expanded coverage, but it also reflects a system where intensity decisions are not always individualized.

A 2025 survey reported in Behavioral Health Business found that 80% of board-certified behavior analysts report no formal training in determining service hours, a systemic training gap in one of the most consequential clinical decisions in ABA treatment planning.

Good UM supports appropriate treatment. Sometimes that means redirecting to a less intensive level of care. And when concurrent services are authorized without coordination, they can fragment care rather than strengthen it. Health plans have a legitimate clinical role in ensuring that services are coordinated and goal aligned.

Getting the Balance Right

What balance looks like at the review level comes down to five best practices.

1. Match reviewer credentials to case complexity. ABA and broader autism cases warrant developmental and behavioral pediatric expertise, not generalist review. Specialty-matched reviewers produce more accurate determinations in both directions because they understand the clinical rationale for a given intensity level — and they can identify when that rationale is missing.

2. Require individualized clinical rationale in every review, not criteria checkboxes. The review record should document why this member, at this developmental stage, does or doesn’t require this intensity. Generic rationale fails on appeal and fails the member.

3. Update criteria to reflect current evidence. If your plan’s ABA criteria haven’t been reviewed against current literature in the past two years, they’re likely out of date. Evidence-based criteria are a prerequisite for evidence-based decisions.

4. Treat concurrent service review as a coordination question rather than a duplication question. The default lens should be how these services work together for this member — not which one to remove.

5. Track denial overturn rates by condition and reviewer type. A high overturn rate on autism-related cases at external review is a signal that the internal review process needs recalibration, not that the criteria need to be tightened further.

Better Outcomes on Both Sides

Health plans that get autism UM right don’t choose between protecting their members and managing utilization appropriately. They achieve both by investing in clinical precision at the review level. The plans that struggle are applying standardized criteria to a condition that is anything but standard.

The difference starts with the reviewer. MRIoA’s network of 700+ state-matched specialists across 150+ specialties includes developmental and behavioral pediatric expertise for every case — where the right call depends on clinical context only a matched reviewer can provide.

Schedule a clinical review consultation to discuss how your autism UM program can deliver better outcomes.

The post The Right Call on Autism: How Health Plans Can Reduce Inappropriate Denials While Ensuring Appropriate Care appeared first on MRIoA.