Efforts to reform the prior authorization process in Medicare Advantage plans remain stalled in Congress despite bipartisan support for the Improving Seniors' Timely Access to Care Act. The bill would establish a process for electronic prior authorization, set standards for attachments and increase transparency. The CMS has introduced regulations to streamline prior authorization, effective January 2026, but the agency is also launching a prior authorization pilot program for conventional Medicare.

The CMS has introduced advanced primary care management and behavioral health service codes for Medicare that could significantly boost primary care revenue for some practices, physician and associate professor of health care policy Zirui Song wrote in a Journal of the American Medical Association viewpoint. However, uptake of similar codes has been hindered by documentation burdens, capacity constraints and patient cost-sharing.

Computer-assisted coding and other AI technology has been widely adopted in health care, but its impacts have been a bit underwhelming, writes certified documentation integrity practitioner Cheryl Ericson. The technology has automated some tasks, but it has also made it easier to assign complex tasks to coding and CDI professionals, who must now be able to spot AI hallucinations and inaccuracies, making critical thinking skills crucial.

~ Cheryl Ericson, RN, CDIP, senior director of clinical policy and education, Brundage Group

Ambient documentation technology was associated with reductions in clinician burnout and improvements in well-being in a study in JAMA Network Open. AI scribes also have the potential to improve clinical documentation accuracy and completeness, which can reduce claim denials and improve cash flow. In addition, they may reduce friction between clinical and revenue cycle teams.

Recent policy changes are expected to leave 14 million more Americans without health insurance over the next decade. The new tax and spending law also limits support programs for providing care to uninsured patients. Sara Rosenbaum, founding chair of the Department of Health Policy and Management at George Washington University's School of Public Health, says the health care system may collapse in communities with limited resources.

Muskingum Valley Health Center in Ohio has developed a value-based care department led by 19 nurses and is participating in the ACO REACH model. The community health center has reduced its medical loss ratio from 104% to 85% and is now projecting a surplus. The Medical Home Network provides MVHC with strategic guidance in practice transformation and risk stratification.

The Social Security Administration currently takes more than 200 days to process initial disability claims, partly due to delays in obtaining medical records, but the Trusted Exchange Framework and Common Agreement can automate and expedite the process. TEFCA's underlying technical specifications and the Qualified Health Information Network Technical Framework will be updated to support government benefits determinations.

OpenNotes allows patients to access their psychiatric records more easily through electronic health records, something that licensed clinical social worker and former patient Andrea Rosenhaft perceives as having advantages and disadvantages. Rosenhaft writes that patients may become distressed or misinterpret information when reviewing their own clinical documentation, and she emphasizes the importance of clinicians writing objective and patient-friendly notes to mitigate these risks.