7 Questions Every Health Plan Should Ask Before Choosing a Utilization Management Solution

The efficiency of a health plan’s utilization management (UM) process directly impacts payer costs, case management operations, and member and provider satisfaction. If a plan’s UM solution is inefficient, it can lead to systemwide errors and costly delays that affect care delivery and administrative coordination.

According to a recent AMA Prior Authorization Survey, 93% of practicing physician respondents reported that the UM prior authorization (PA) process resulted in care delays and abandonment. Another 86% found the administrative burden associated with PAs to be high or extremely high.  

 While many health plans still rely on time-consuming, manual processes for utilization management, more recent advances in UM automation aided by data science and embedded artificial intelligence (AI) have vastly improved care approval processes, methodologies, and outcomes. Payers now have the opportunity to transform not only their UM workflow process, but also the interoperability of their UM system with other internal departments, as well as external third parties. 

For the health plan that is considering upgrading or replacing their UM system, it is more important than ever to ask the right questions of their potential solution provider. Here, we explore seven important questions every health plan should ask before choosing a UM solution. 

1. How does the platform make the UM process more efficient?

By leveraging automation through AI, efficiencies can be realized at every step of the UM workflow process. Automation enables formerly manual tasks and authorizations to be auto routed into work queues to reduce administrative work. The development of a fully configurable auto-auth rules engine ensures fast processing time for authorizations that do not require a human review. And full end-to-end letter automation saves considerable time and resources for routine approval letters. 

The ability to bring in real-time benefit information at the beginning of the process – for example, notifications about excluded services or network restrictions - is another way a well-designed UM system can help make the UM process more efficient. Many current systems are not integrated with benefit information, so it is possible to go through the entire authorization process and not realize until claims payment that the prior authorization wasn't even required, or that the patient needed to go to a certain type of facility (e.g., a Center of Excellence). By injecting real-time data into the process, decisions can be made much earlier in the process, significantly increasing efficiency and reducing member and provider abrasion. 

2. How does the platform streamline the clinical review process? 

The clinical review process can be expedited with the implementation of AI-enabled tools and intelligent workflows that personalize, predict, and approve agreed upon conditions and services. By utilizing built-in workflows with the same integrated clinical guidelines and decision support criteria between payers and providers, the prior authorization process becomes streamlined and operational cost savings between payer and provider organizations are maximized. 

Blog:  How AI and Automation Create Efficiencies in Utilization Management Workflows (INFOGRAPHIC)

3.  How does the platform support the audit and case review process? 

A modern UM solution should feature a full audit trail which tracks every step of the UM process and includes detailed entries on what was done, who did it, and when it was completed. It should also feature a comprehensive suite of reporting dashboards to support audits and day-to-day operations. In this way, a complete and real-time snapshot of authorizations, events, appeals, and grievances is created, enabling the entire care team to work from a single source of truth. 

4.  Is the platform configurable? 

Every health plan is different, so a UM platform with a configurable rules engine for auto authorization, auto routing and correspondence just makes good business sense. Data fields and values can be configured for line of business to support a variety of business use cases, ensuring the unique needs of each client can be met – without the need for additional IT support. 

5.  How will the platform help my organization transition to a value-based model? 

A critical part of the shift to a value-based care model in the payer space is aligning with providers to improve patient care. At the core of value-based care coordination is the proper communication and sharing of medical information, as well as using this data effectively - whether it be improving member engagement, focusing on wellness and preventative care, or transferring to whole patient care coordination. A UM system that offers data-driven, real-time insights and a single data layer helps to ensure that all parties are always on the same page around member information. 

Data-driven AI also provides actionable insights into UM trends and patterns based on provider, facility, procedure, condition, and member demographics (such as geographic location, gender, age, etc.). By leveraging embedded data science and predictive AI, a modern UM solution can aid clients in shaping their UM business practice to promote value-based and whole-person care.  

6.  Can the UM solution align with Care Management and other internal departments? 

Many health plans currently use multiple platforms to manage UM activities, which require duplicate documentation and logging into multiple systems. The result is often reduced speed and accuracy.  

With a dynamic, cloud-native UM system utilizing real-time data feeds, information is available in the same platform with just a few clicks, reducing errors and saving time. In this way, administrative staff across departments can more quickly secure authorizations for the procedures, treatments, and prescriptions that members need to improve health outcomes, as well as seamlessly navigate appeals and grievances. 

7.  How easy is it is to learn a new UM platform, and more importantly, train staff? 

Replacing a UM system can be a complicated, time intensive, and expensive process, but it doesn’t have to be. A modern UM solution will feature an intentionally designed, user-friendly interface, complete with a built-in best practice workflow that intuitively guides the user through the authorization process. The system should feature context-sensitive help and tooltips to assist new users learn and understand features as they go.

Many legacy UM systems only house a few pieces of the UM puzzle, and users must access additional systems to see benefit information or the member‘s medical history.  This adds to training time as users must be trained on multiple systems instead of just one.  When all the information needed to complete the end-to-end UM process is consolidated and readily available in the UM platform, users can be fully trained in a fraction of the time. 

Vital Data Technology is a data science-driven healthcare solutions company giving payers, providers, and members the power to drive efficiencies and improve clinical and financial outcomes throughout the healthcare ecosystem with their proprietary artificial intelligence-enabled platform, Affinitē™. The platform transforms data into actionable insights using artificial intelligence and advanced analytics integrated with embedded HEDIS® and risk adjustment logic. Affinitē is purpose-built and flexible, deployed as a cloud-based, end-to-end solution or as distinct modules listed below to help with your business needs. 

Designed specifically for health payers, Affinitē Utilization Management (UM) uses intelligent automation to streamline workflows, verify benefits, and complete time-consuming administrative tasks - freeing-up valuable clinical staff to target only those complex cases that require their expertise. Unlike other similar platforms, Affinite UM incorporates advanced analytics and machine learning for continuous improvement - suggesting new rules for automation, new benefit designs, and better operational paths that lead to improved outcomes and significant cost savings.