Thursday, June 11, 2026

A federal Office of Inspector General (OIG) investigation revealed Medicare Advantage plans denied prior authorization requests for inpatient rehabilitation at unusually high rates, often reversing denials when beneficiaries appealed. The report specifically examined skilled nursing and inpatient rehab facility admissions, finding plans used clinical criteria more restrictive than Medicare coverage rules and denied medically necessary care. For practices submitting inpatient rehab authorizations to MA plans, this report signals heightened scrutiny from CMS on plan behavior. Monitor for potential CMS enforcement actions or clarifications on medical necessity standards for post-acute care. This could affect your appeal strategy for 2026 denials.

The House Appropriations Committee voted to block funding for CMS's proposed WISeR model, a Medicare Advantage pilot that would have used artificial intelligence to automate prior authorization decisions for certain services. This legislative step reflects bipartisan concern over algorithmic bias and lack of transparency in automated decision-making. While the pilot is now unlikely to launch in 2026 as planned, the underlying pressure to streamline PA processes remains. Private payers are still actively deploying their own AI tools for utilization management. This outcome removes a specific near-term federal change, but does not alter the broader industry trend toward automated reviews.

The AMA's CPT Editorial Panel updated its coding taxonomy to better classify artificial intelligence services in medical practice. The changes aim to create clearer pathways for reporting and reimbursing AI-assisted clinical decision-making, image analysis, and predictive analytics. This is a foundational step toward standardizing how practices bill for AI tools integrated into workflows, like computer-assisted detection in radiology or algorithm-driven diagnostic support. No new CPT codes are finalized yet, but the updated taxonomy sets the stage for future code proposals and payer policy. Billing teams should track CPT panel meetings for new Category III or Category I codes emerging from this framework, likely affecting 2027 code sets.

The Improving Seniors' Timely Access to Care Act, a bipartisan bill to streamline Medicare Advantage prior authorization, was reported favorably out of committee and is now eligible for consideration under the House's suspension calendar. The legislation would require MA plans to establish electronic prior auth programs, respond to urgent requests within 24 hours and standard requests within 72 hours, and publicly report their denial rates. This procedural move indicates momentum for the long-stalled reform. The suspension calendar is for non-controversial bills, suggesting potential for swift House passage. Watch for a floor vote date; Senate companion bill S. 4542 is pending.