Health insurers and health care provider organizations are increasingly using artificial intelligence (AI) tools in prior authorization and claims processes. AI offers many potential benefits, but its ...

California is among a handful of states that seeks to regulate the use of artificial intelligence (“AI”) in connection with utilization review in the managed care space. SB 1120, sponsored by the ...

Health systems and health insurance plans spend enormous sums of money battling over how to be paid fairly — and these battles have only intensified with the growth of Medicare Advantage plans, which ...

Concurrent review is a utilization review process that occurs while a patient is actively receiving treatment, such as during a hospital stay. It evaluates the medical necessity and appropriateness of ...

California Gov. Gavin Newsom recently signed two bills regarding artificial intelligence (AI) regulations in the healthcare sphere. The first bill (SB 1120) requires a qualified human individual to ...

Humana will use healthcare technology firm XSOLIS’ predictive analytics platform to streamline parts of the utilization review process with providers. The payer will adopt the company’s various ...

I need to do a drug utilization evaluation (DUE) for a new product to be added to our formulary. What resources are available to develop a DUE? The formulary system encompasses facets of medication ...

Medicaid managed care utilization review data for mental health services were analyzed for the calendar years 2017 and 2018. These data indicate low rates of utilization review denials for both ...

Cone Health is a North Carolina-based nonprofit health system serving patients across 150 locations, including five hospitals and more than 120 physician practices. It had a peer review paper-based ...

Whether pharmacies have a due process interest in determining whether an injured worker's care is necessary under the Workers' Compensation Act was one of the key arguments in the first session led by ...