The U.S. District Court for the Eastern District of California, in an order filed March 31, 2025, issued a mixed ruling on Cigna’s motion to dismiss the PxDx algorithm-focused putative class action (Kisting-Leung, et al. v. Cigna Corporation, et al.),… Read More ›
The Centers for Medicare & Medicaid Services (CMS) finalized important updates impacting prior authorization of care processes within the Medicare Advantage (MA) program. These changes, detailed in the CMS 2026 Medicare Advantage Final Rule (“Rule”), aim to enhance beneficiary protections… Read More ›
On April 7, 2025, the Centers for Medicare & Medicaid Services (CMS) released the Calendar Year (CY) 2026 Rate Announcement and final rule for Medicare Advantage (MA) and Part D programs. Notably absent from this final regulation were specific guardrails… Read More ›
On February 13, 2025, a federal court dismissed several state law claims against UnitedHealthcare but allowed breach of contract and good faith claims to proceed in a case alleging improper use of AI to deny medical coverage. More specifically, the… Read More ›
The Centers for Medicare & Medicaid Services (CMS) has released a proposed rule that would significantly enhance regulations around how Medicare Advantage (MA) organizations use internal coverage criteria, particularly relating to prior authorization and utilization management. The proposed changes, part… Read More ›
Medicare Advantage insurers are using prior authorization requirements to systematically deny seniors access to post-acute care facilities, according to a recent U.S. Senate investigative report. Dated October 17, 2024, the Majority staff report of the Senate Permanent Subcommittee on Investigations… Read More ›
CMS is proposing revisions to the required metrics for the annual health equity analysis of the use of prior authorization. Under the proposed changes, MA organizations would have to report the metrics for the analysis by each item or service,… Read More ›
New regulations requiring Medicare Advantage (MA) organizations to ensure non-discriminatory use of artificial intelligence and automated systems have been proposed by the Centers for Medicare & Medicaid Services (CMS). These AI provisions are part of a broader proposed rule titled… Read More ›
According to the Centers for Medicare & Medicaid Services (CMS), the Medicare Advantage program has now exceeded 50% of Medicare enrollments and in order to further increase transparency and strengthen programmatic data, on January 25, 2024, the agency issued a… Read More ›