Friday, April 17, 2026

CMS published a proposed rule targeting prior authorization for drugs under Medicare Advantage, Medicaid Managed Care, and CHIP. The rule would mandate a 72-hour standard turnaround for urgent requests and require payers to provide a specific reason for any denial, including citing clinical criteria. It also proposes electronic prior authorization standards aimed at reducing provider burden. The rule applies broadly to MAOs, Medicaid plans, and QHP issuers. The comment period closes mid-June 2026, with an expected effective date in 2027. Monitor the comment period on CMS-2025-XXXX for final details.

UnitedHealthcare announced it will eliminate prior authorization requirements for most services provided by rural and critical access hospitals and their affiliated professionals. This policy change is immediate for participating providers in designated rural areas. The waiver covers most non-elective inpatient and outpatient services, but excludes cosmetic procedures, some advanced imaging, and certain durable medical equipment. Rural practices with UHC contracts should confirm their eligibility on the UHC provider portal and adjust their internal authorization workflows this week. This move aims to ease administrative burden and could significantly reduce front-office work for affected clinics.

Amperos Health secured $16 million in Series A funding led by Bessemer Venture Partners to scale its AI-powered denial management platform. The company's software uses large language models to automate the identification, analysis, and appeal of claim denials. This capital infusion signals continued investor and provider interest in automating high-touch, labor-intensive RCM tasks. While the platform is in early stages, its development reflects a broader industry trend toward using AI to address rising denial rates and shrinking margins.

In a historic shift, the administration has moved state-licensed medical marijuana from Schedule I to Schedule III under the Controlled Substances Act. This reclassification acknowledges accepted medical use and lower abuse potential. It does not change federal illegality but eases research restrictions and could pressure insurers, including Medicare and Medicaid, to reconsider coverage policies in states where it is legal. The change is immediate but does not mandate payer coverage.

UnitedHealthcare is eliminating most prior authorization requirements for providers in designated rural areas as part of a financial stability initiative. The change applies to both commercial and Medicare Advantage plans. Rural practices with UHC contracts should check their portal for notification and confirm which services are now exempt. This is an operational shift; update your front-desk and billing workflows for UHC patients in eligible ZIP codes immediately to stop submitting unnecessary PA requests.