Utilization management (UM) ensures patients receive health care services that are appropriate, necessary and cost-effective. UM functions, including prior authorization (PA), are critical for both traditional and specialty treatments and services, which involve complex patient management and varied administration locations.
However, new legislation and breakthrough technological innovations are beginning to shift UM policies and practices, for better and for worse.
Below, we’ve pulled some highlights from our white paper about the rapidly changing present and future of UM.
The evolving regulatory landscape for utilization management and prior authorization
Increased media attention and public scrutiny around UM have led to heightened regulatory pressure at both the state and federal levels:
- The Centers for Medicare & Medicaid Services (CMS) has introduced regulations intended to improve the electronic exchange of health information, streamline PA processes and reduce disruptions for beneficiaries.
- At the state level, legislation seeks to restrict UM, with proposals ranging from eliminating certain UM solutions to mandating same-state licensure for clinicians conducting utilization reviews.
These regulatory changes, among a number of others, underscore the need for payers and providers to stay informed and adaptable in order to navigate the shifting landscape effectively.
Utilization management and prior authorization trends
Some payers and insurers are adapting to regulatory pressures by reducing PA requirements, replacing traditional PA with new processes and/or incorporating new technologies into their systems. These changes aim to enhance the PA process, reduce administrative burdens and maintain patient safety.
A few key trends include:
- Expanding the role of electronic prior authorization (ePA), which can reduce turnaround time and streamline processes.
- Deploying artificial intelligence (AI) to appropriately automate PA approvals while ensuring that adverse decisions are reviewed by qualified professionals.
- Gold carding, which allows providers to bypass PA for certain services if they meet specific criteria, such as consistently high approval rates.
Certain evolutions, like ePA and AI, are being utilized to streamline the PA process, ensuring timely and accurate approvals. However, other changes—such as gold carding—have the potential to be more detrimental. And bypassing PA entirely could lead to increased health care costs, low-value care and potential patient safety risks.
Keeping up with new regulations and legislation for utilization management
Evernorth is actively engaged in public policy debates, advocating for pharmacy and medical management policies that align with our mission to provide affordable, equitable and evidence-based care. Our State Government Affairs team prioritizes high-impact issues and engages lawmakers to develop sustainable policy solutions.
Key strategies surrounding UM include:
- Advocacy: Supporting legislative proposals that expand payer choice and flexibility.
- Expertise: Leveraging clinical expertise to inform policymakers and develop sustainable policy solutions.
- Innovation: Implementing tech-enabled pharmacy and medical processes to streamline UM for our stakeholders and ensure timely patient care.
The future of utilization management in health care
The future of UM lies in integrating data-driven insights and technology to create a more efficient, patient-centric system. By focusing on holistic UM tools centered around individual patient care, we can transition from isolated transactions to collaborative management. Innovations such as predictive AI and advanced algorithms are enhancing UM effectiveness, ensuring patients receive necessary care promptly and safely.
As the landscape continues to shift, we’re investing in tech-enabled processes to simplify UM, reduce administrative burdens and ensure timely access to care.
Click here to have the full white paper emailed to you.
