Optimize programs to ensure medically necessary, care setting appropriate, high quality, and clinically optimal care delivery is delivered while minimizing member and provider abrasion
A best in class Utilization Management (UM) function has several critical sub-functions (prior authorization, concurrent review, utilization review, retroactive review, appeals and grievances) and is closely integrated with other enterprise functions (e.g., care management, customer service, claims, processing and payment, provider contracting).
Health plans that do not continuously manage and evolve their UM function can risk erosion to their cost competitiveness and risk abrasion/confusion within members and providers when not executed effectively.
Increasingly, UM has also become a competitive differentiation, as payers increase clinical integration across medical management functions, productize components of UM, and use advanced automation/AI capabilities to improve efficiency.
Common issues we help our clients solve
How can we evolve our UM approaches to reduce administrative hassle (for us and our provider partners) and reduce member and provider abrasion?
What ROI are we achieving on our Utilization Management programs?
What are the market best practices for Utilization Management operations?
How can we optimize Utilization Management admin costs through technology and automation?
How can we better integrate Utilization Management with other plan functions?
How can we monetize Utilization Management for ASO employers?
How can we best leverage the “real-time” information available through prior authorization and concurrent review to proactively engage with members and drive enhanced affordability and quality outcomes and improved member experience?
Operational Optimization
Continuously assess current processes, staffing models, and enabling infrastructure to compare against leading practices to identify opportunities for improvement.
Evaluate their Prior Authorization list to develop “code level ROI” and compare against other plans to identify optimization opportunities.
Assess medical policies to identify opportunities to clarify and tighten criteria to avoid provider abrasion.
Conduct actuarial evaluation of program outcomes to evaluate against high performing benchmarks.
Optimize Provider Engagement
Evaluate gold-carding opportunities for targeted providers based on demonstrated consistent historic and expected performance (including continuous monitoring).
Improve provider UM transaction processing including improved submission of clinical documentation and increased adoption of automated channels for UM interactions.
Recognize opportunities to integrate UM performance metrics in value based care arrangements and/or provider partnerships that titrate UM efforts based on provider expectations and outcomes.
Utilization Management Productization
Know that while a strong base of Utilization Management programs is a core competency, expanded and embedded UM capabilities create opportunities to monetize select UM activities to increase revenue and align with customer expectations.
Select examples of UM productization include:
Products that integrate Advocacy with enhanced UM to steer members to preferred sites of care, tiered UM offerings that allow customers to buy-up to higher levels of utilization management, shared savings UM monetization.
Advanced Analytics and RPA
Improve execution of utilization management processes by applying advanced analytics and robotic process automation disciplines to inform and reduce effort to arrive at clinical decisions.
Select examples include:
Natural language processing applied to clinical content to identify criteria matches or gaps required to inform clinical decisions,
AI and ML analytics to identify provider patterns or develop “pre-decisioning” output
RPA to automate manual documentation tasks.
Roadmap components result in:
Improved program outcomes, reduced costs to deliver, reduced provider/member abrasion, quality care for members
There are a several critical success factors for plans to optimize UM.
Define an UM strategy and roadmap in context of broader enterprise strategy
Orient UM activities around areas of highest impact and measure performance
Proactively manage member and provider abrasion
Continuously enhance processes and teaming models to optimize admin burden and reduced provider and member abrasion
Use vendors appropriately to enhance outcomes
Oliver Wyman has extensive experience with helping plans optimize their UM functions and design and implement next-generation UM strategies and operating models.
Evaluated strategic trade-offs of different Utilization Management monetization and integrated product approaches and of different gold carding strategies tied to provider performance; identified opportunities to enhance and harmonize the plan’s UM programs to generate $25M claims savings. Read more
Developed a detailed playbook outlining the required future state utilization management organization design, operating model, and enhanced workflows and identified cost saving potential of $50M+ annually. Read more
Defined a roadmap for continued UM integration with Care Management and Member Advocacy and Concierge products to enhance medical cost management. Read more
Performed detailed operational and value delivery assessment of 25 medical management programs–including the full utilization management function–and identified opportunities to improve current program operations, reduce cost to deliver, and improve ROI. Read more
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