This Week in Pulse Check: Trust, Control, and Who Pays the Price

Hey y’all,

Big policy energy this week.

CMS (& like.. the rest of the country) wants real-time prior authorizations. Durable Medical Equipment enrollments are frozen — affecting americans' access to cpap machines, breast pumps & wheel chairs. AND there’s new guidance around diagnosing endometriosis (i’m obsessed).

The rules are changing. Whether the infrastructure can keep up is the real question.

Let’s dive in.

— Nadine Peever

PS - We’re building something new for the Bonne Fire ATL community and would love your input. It’s a three-question member survey and it will directly shape what we launch next. If you have twenty seconds, fill it out here →

A KFF poll out this month found 69% of insured adults find prior auth burdensome, with one in three calling it a "major burden” (is anyone surprised?). That ranks higher than understanding your bill, getting an appointment, or finding an in-network provider. Among people managing chronic conditions, 4 in 10 say it's their single biggest obstacle to care. We’re all so tired.

So what is it, exactly? Insurers require approval before patients can access certain medications, procedures, or referrals. In theory, a check against unnecessary care. In practice, physicians are faxing paperwork and patients are waiting days or weeks. Many argue it's become a cost-containment tool dressed up as clinical oversight. They're not wrong.

The Medicare Advantage problem: Nearly 99% of Medicare Advantage (MA) enrollees need prior auth for at least some services. The previous administration tried to mandate reporting on how MA plans use it. The Trump administration's 2026 MA final rule dropped that requirement.

Where it gets complicated: The administration has been openly critical of prior auth overuse in MA, yet CMS just introduced it into traditional Medicare for the first time. The WISeR (Wasteful & Inappropriate Service Reduction) pilot launched January 1 in six states covering 17 services deemed high-fraud or low-value. Critics on both sides have concerns. Both are legitimate.

The rule to know: CMS-0057-F took effect January 1, 2026. Payers must use FHIR APIs to process requests, provide specific denial reasons, and respond within 7 days standard, 72 hours urgent. It’s the biggest prior auth overhaul in years. Whether payers can execute is the open question. (Editors note: I probably cite this rule a dozen times a week — it’s a big one.)

What CMS is saying: At the AMA's National Advocacy Conference, CMS Deputy Administrator Chris Klomp was refreshingly direct: prior auth was weaponized in the 1990s and fractured physician-payer trust in ways that still shape both sides' behavior. His goal is no human touching prior auth, replaced by real-time AI-driven determinations. Timeline: "double-digit months." The obstacle isn't the technology. It's a fragmented vendor landscape where APIs don't talk to each other. His ask to physicians: pressure your vendors to standardize, or the policy won't matter.

As of February 25, new DME suppliers (durable medical equipment) cannot enroll in Medicare. The six-month moratorium was announced at a joint press conference with VP Vance and Dr. Oz as part of a broader anti-fraud push.

So why DME? It's a sprawling category: oxygen concentrators, power wheelchairs, CPAP machines, prosthetics, insulin pumps, hospital beds, catheters. High volume, hard to audit, and suppliers are often small independent businesses far removed from the clinicians writing the prescriptions. That distance creates gaps. Oz cited KFF's estimate that $300B a year goes to fraudulent, abusive, or wasteful healthcare spending. The federal share is around $100 billion.

What's still unclear: Which subcategories are actually in scope, and what the exception process looks like for legitimate suppliers already mid-enrollment. That ambiguity is going to hit small independent operators the hardest.

The Minnesota context: On the same day, the administration withheld $259M in federal Medicaid reimbursements from Minnesota. The backstory traces to a COVID-era scandal where 47 people were indicted for allegedly stealing $250M from a child nutrition program. Walz has 60 days to submit a corrective action plan. No plan, and deferred payments could reach $1B by year's end.

Walz called it retribution. His Attorney General is hinting at a lawsuit. Federal judges have blocked similar funding freezes before, and this one will almost certainly face the same test.

What to watch: If your work touches home health tech, post-acute care, or medical device distribution, pay attention now. The policy is moving faster than most compliance teams are tracking.

Read more →

As always, thanks for reading. Enjoy the weekend, y'all.

Luv, Nadine