UM and prior authorization, which is the most commonly practiced form of utilization management, are both highly regulated, and health plans can face high penalties and fines when they are out of compliance. The existing US nursing shortage is another factor exacerbating the pain for payers who struggle to render decisions in a timely manner. At our December 6 AHIP-hosted webinar, key insights into the value of UMaaS were shared by Sagility’s Senior Vice President of Clinical Practice Krithika Srivats and Mike Van Den Eynde, Managing Director at Deloitte, including:

• Transformational intelligent automation and technologies
• Comprehensive UM process that maximizes efficiency, improves clinical care quality, and improves compliance to CMS mandates
• Clinician shortage mitigation
• Leveraging organizational capabilities in provider network quality
• End-to-end solution for a seamless provider experience and lower cost-per-auth

As part of the webinar, Sagility polled attendees and shared results representing key UM trends:

• For our poll regarding “What is your readiness to meet the CMS electronic and interoperability mandate?,” 75% of respondents are “In planning,” while 25% of attendees have a program “in development.”
• For poll two, “Do you have a comprehensive approach to your UM program?,” our attendees were evenly split, with one-third answering “Yes,” a third answering “No,” and the remainder with a “Partial approach.”
• Finally, with Poll 3, “Have you considered outsourcing your UM in full or part,” we determined that 50% of our attendees are not outsourcing but would consider doing so in the future.

With our post-webinar QandA session, Krithika and Mike provided critical insights into attendees’ questions.

Question: What are the technology requirements of the entity using the solution?

Response: We do think there are going to be some new capabilities needed to make this all work. There is more interoperability, and FIHR-based intake is going to be needed. Second, rules engine capability can do a range of components and get to making decision on subcomponents of the prior authorization, versus just in total. So it will take some doing to get there. We don’t think too many health plans have that level of rules sophistication to do all of this right off the bat.

Question: Our organization offers both government-sponsored products and commercial. The nursing shortage and clinical costs have really affected us greatly in staffing and spend. For our government-sponsored product, we can’t offshore clinical review. But for commercial product, we can. How can we address these issues?

Response: I think there are a couple of questions in that. Outsourcing has steadily increased over the past 8 to 10 years, and more and more commercial plans have offshored in that time. But we are also seeing in the past 3 to 4 years that many Medicare Advantage plans have also taken to outsourcing, particularly offshoring. Especially because of the recent nursing shortage—that demand has grown significantly. Where we do see hesitation is in the state-sponsored or Medicare-managed Medicaid plan, especially because there are two parts to that restriction—one is coming from their commitment to leveraging their in-state resources, but also finding the right nursing licensure offshore can be sometimes challenging. So in those cases, there are a couple of different options. The first thing is having automation built in for some of the clinical reviews. That is actually very beneficial with resource optimization. A clinical decisioning engine takes the burden off what falls into a clinician’s bucket. And then there are other creative ways to leverage some of the global talent in that you could decouple the process and have an onshore licensed clinician do an audit and 100% of the cases and release. There are other creative ways, as well, but I would say technology and having a tier one and tier two automation process would be the first pass at that.

Question: Like all government-sponsored plans we did not prior authorize services during Covid-19 and had reinstituted the prior authorization requirement in January 2023. For nearly a year now, we have been really struggling with both SLAs and a significant increase in volume of cases to handle. Can you offer three things we need to do to improve our operations?

Response: A full UM program really starts by looking at what are the trends driving the volume. Historically, I think plans have used a catch-all mechanism for prior authorization. But hopefully in this webinar we looked at UM as more than just managing volume. So how do we comprehensively look across the trends and use provider behaviors—look at network case rate optimization, etc—to become a full program? That way you aren’t just looking at the volume increase, you are looking at the trends in cost of care. I would say that would be one way to look at it. Again, using automation is one way to address the volume directly. So if you can automate some of the high-volume cases with clinical criteria that can support at least 60 to 70% of that process, there is management capability that comes from there. I would say auto approving those procedures that are not yielding high value helps keep an eye on trend without putting high cost to manage volume. So that is probably one way to look at managing the post-Covid volume.
It’s really analysis, analysis, analysis, from an ROI standpoint. From an operational perspective, look at how many you take in and is there any way to reduce the denominator, so you request less of them? And keep the subset so there is more opportunity of improving outcomes and think about it more from the clinical standpoint than you have in the past. Understand by category where you have more clinical impact than less, and base where less clinical value and more clinical value.

To view the replay of this compelling webinar, go to : https://sagilityhealth.com/post-ahip-webinar/

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