Healthcare's utilization management crisis didn't start with artificial intelligence — but AI threatens to make it exponentially worse if we don't change course now.
A recent peer-reviewed study from Stanford University, published in the January 2026 issue of Health Affairs, evaluated 21 predictive and/or generative AI tools currently deployed across the utilization review landscape. The findings should serve as a wake-up call: we're
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AI Didn’t Fix HCC Coding—It Made It Harder. This is How to Fix It
Hierarchical Condition Category (HCC) coding is one of the areas in healthcare where AI is the obvious solution. On paper, it makes perfect sense. Use it to scan charts, identify diagnoses, group them into risk categories, and more efficiently predict future healthcare costs. In Medicare Advantage and value-based care, where risk adjustment directly impacts reimbursement, it sounds like a natural fit. But reality tells a very different story.
If you want to understand what is actually
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How CMS Policy Just Shifted 30% of Shoulder Surgeries Out of the Hospital
A Shoulder Replacement Case Study
The Bottom Line: When CMS makes a procedure ASC-payable, the shift is fast, measurable, and concentrated in certain territories. Here's what total shoulder arthroplasty can tell us about where the site-of-service mix for hundreds of procedures is headed.
In July, I broke down the 2026 OPPS Proposed Rule and called it a gold rush. The first tranche just hit: 285 procedures came off the inpatient-only list on January 1. The remaining 1,400+ will phase out by
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Why Health Systems Are Outsourcing Tech Support to Drive Adoption
Patient portals are an important piece of any healthcare organization’s digital engagement strategy, and they’re key to getting the most out of your EHR. Portals serve as a hub for care management, billing, and communications. The technology enables a unique convenience for providers and patients alike.
Yet, many healthcare organizations see engagement plateau after go-live. According to the National Library of Medicine, only 15% to 30% of patients use even a single portal
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From Burden to Breakthrough: Why Ambient AI is the New Frontline of Clinician Support
Despite advances in technology and new solutions across the entire health landscape, physician burnout remains one of the most urgent challenges in healthcare, driven largely by continued administrative and documentation overload. While more than three-quarters of clinicians describe their work as meaningful and rewarding, they also describe a practice environment that has become increasingly unsustainable.
Administrative obligations, inbox overload, and the constant pressure to
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How to Prepare Your Healthcare Organization for Delegated Credentialing and NCQA Audits
Every growing provider group eventually hits the same wall. The credentialing team is overwhelmed. Enrollment timelines are stretching to four and five months. New providers are sitting idle while the revenue they should be generating disappears into an administrative queue. Someone in the room suggests delegated credentialing as the solution, and the conversation usually goes one of two ways.
The first path: leadership moves fast, pursues a delegation agreement with a major payor, fails the
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The Cognitive Aftercare Gap: Cancer Care is Data-Rich, but Brain Recovery is Unmanaged
Cancer care has become better at keeping people alive. What it is still learning to do is help people think clearly again after treatment.
Cognitive symptoms after cancer are common, clinically meaningful, and routinely under captured. People describe slower recall, reduced attention, weaker working memory, and mental fatigue that makes daily tasks feel heavier than they should. Clinicians hear it as “brain fog.” Health systems often treat it as an unfortunate side effect rather than a care
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How AI Vocal Biomarkers Are Turning Speech Into a Vital Sign
Early detection has always been one of medicine’s most powerful tools. The sooner we can identify cognitive, behavioral, or neurological conditions, the greater the potential benefit for patients, their caregivers, and their providers.
That truth is even more pressing today. Thanks to rapid advances in artificial intelligence and speech analysis, vocal biomarkers have emerged as a fast, accurate, and non-invasive way to screen for a growing range of conditions. The ability to
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OBBBA: From Compliance Crisis to Digital Transformation Catalyst
The implementation of the “One Big Beautiful Bill Act” (OBBBA) and several policy milestones rolling out through 2028 will redefine how Americans access and pay for their care. For health system strategists and IT leaders, OBBBA is an opportunity to reimagine the entire operating model.
Between tighter margins and the rising demand for a more integrated patient experience, new regulations are a litmus test for transformation. Simply trimming costs or leaning on old ways of working will no
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Employers Are Buying Health Insurance Blind: It’s Time to Demand Data Transparency
Employers spend a fortune on health insurance. Health benefits are often their second-largest expense after payroll. Yet employers often make these purchases without knowing how their health plans function when employees need care.
Health insurance differs from other major purchases, in that payment doesn’t guarantee access. Employers and their workers pay frontloaded, expensive premiums only to find that when they attempt to use these benefits, their requests are denied or delayed.
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