Prior Authorization Insights

August 2, 2026 · 5 min read

When Independent Judgment Becomes Difficult to Verify

Iowa's House File 2635 doesn't just require documentation of a prior authorization denial, it requires that a clinician's independent judgment actually occurred before the decision was reached. That raises a harder question: what evidence would prove it did?

July 26, 2026 · 4 min read

What Changes When One System Runs Both the Denial and the Appeal

Cohere Health's expansion of Cohere Unify into appeals raises a structural question: when the same clinical intelligence system produces both the authorization and its appeal, does the appeal still provide an independent review?

July 19, 2026 · 5 min read

What Low Appeal Participation Reveals About Prior Authorization Decisions

An OIG report found that Medicare Advantage organizations overturned 95% of appealed skilled nursing facility prior authorization denials, while only 18% of denied requests were appealed. That combination raises questions about the denials that never receive another review.

July 12, 2026 · 5 min read

When Prior Authorization Becomes a Navigation Problem

Clinical policy explains what a payer requires for approval. It does not always explain how that payer actually operates once a prior authorization request enters the administrative process.

July 5, 2026 · 5 min read

When Prior Authorization Comes Before the Clinical Policy

Prior authorization can begin before a clinical policy is publicly available. That creates a transparency problem around how coverage decisions are evaluated until standardized criteria are published.

June 28, 2026 · 5 min read

What CMS Audits Add to Prior Authorization Transparency

CMS audits and Corrective Action Plans add a separate layer of visibility to prior authorization transparency: not just what plans report, but what regulators review, cite, and require them to correct.

June 21, 2026 · 5 min read

What an Overturned Denial Is Actually Measuring

An overturned prior authorization denial is not a single operational event. It can reflect new documentation, a different interpretation, or external review, but those pathways disappear once the outcome becomes a reported rate.

June 14, 2026 · 6 min read

Prior Authorization Requirements and Workflow Clarity: Two Separate Problems

Publishing prior authorization requirements and creating operational clarity around those requirements are separate problems. The denial itself often does not explain what actually needs to change before resubmission.

June 7, 2026 · 5 min read

The Denial Rate Has a Resolution Problem

Prior authorization denial rates are reported as a single outcome category. The operational pathways producing those denials are not reported at all.

May 31, 2026 · 6 min read

Before the Decision and After It: The Hidden Labor Cost of Prior Authorization

Across interviews with utilization management and hospital operations professionals, a recurring pattern emerged: prior authorization metrics capture outcomes, while the operational burden surrounding those outcomes remains completely invisible.

May 17, 2026 · 6 min read

UnitedHealthcare Is Cutting Prior Auth for 30% of Services. Here's What That Actually Covers.

UnitedHealthcare's 30% prior authorization reduction sounds broad, but the impact depends on the denominator: prior authorization applies to about 2% of its medical services. This analysis looks at what the announcement changes, what it does not, and why service-level reporting matters.

May 10, 2026 · 8 min read

Prior Auth Transparency Is Live. Most of It Isn't Usable.

Original analysis from 1,300+ health plan entries on what is actually missing from the first year of CMS prior authorization transparency reporting.