Reimagining utilization management: The journey to precision UM

March 24, 2022

Healthcare is never stagnant. Its stakeholders are always working to improve processes in the pursuit of providing high-value care: high-quality, low-cost care with excellent patient outcomes and experience.

That pursuit was why utilization management (UM) efforts began in the first place, as health plans attempted to align incentives with providers in a fee-for-service world. By reviewing procedures based on medical policy guidelines, health plans could play a role in making sure care was appropriate before paying for it.

While prior authorization and managed care techniques play an important role in helping members access safe and effective care, it’s become abundantly clear that current UM procedures cause friction and don’t contribute to a positive experience for patients, providers or health plans.

That’s because it’s a clinically complex and often manual process. Health plans receive requests from a variety of channels, from portals to phone calls to faxes. They are burdened with review and approval for increasing numbers of procedures, and sometimes receive prior authorization requests for procedures that don’t even require one. On the other side of the fax machine, providers have to determine which clinical documents each health plan requires to approve payment with requirements changing 8% monthly.

At its worst, UM can leave members waiting to access care they desperately need.

It’s time to reimagine the whole process. Certainly the industry our lives depend on deserves the most current technology. With Olive, utilization management can evolve from its fax-dependent, friction-ridden current state to one that previously seemed impossible.

Creating new connections

Providers and payers deserve a UM platform that not only improves their communication and cuts down on unnecessary, back-and-forth phone calls and faxes, but truly unleashes data and enables the flexibility needed to support local market strategies — the ability to do more authorizations without increasing costs. Olive’s UM Transformation capabilities do just that.

Olive automatically reviews incoming electronic authorization requests on behalf of the payer and enables payers to automatically approve authorizations when medical necessity is met.

If the request satisfies all requirements, Olive recommends them for approval — freeing up nurse and physician time for the most complex cases. For reviews that do need a human touch, Olive’s AI assistant guides reviewers with real-time, relevant data so they can work smarter and perform more accurate reviews.

With this level of connection and capabilities, providers are able to do less work to submit prior authorization requests, health plan administrators require less time to approve them and members get needed care quicker through reduced care delays. That amounts to reduced variability in approvals, improved member satisfaction and lower operating costs.

Health plans can also bring their utilization management efforts in-house — gaining direct access to their UM data to better understand their patients and how to care for them.

All of this lays the groundwork for the ultimate utilization management goal: precision UM.

Pursuing precision UM

Once health plans have real-time, comprehensive visibility into their UM data, they can take the next step toward a value-based system by providing precision utilization management.

Precision UM is when health plans use their data and artificial intelligence to ensure members get the right care at the right time, minimizing medically unnecessary care.

They can detect provider spend variation, compare provider alignment with medical necessity guidelines and check member outcomes — and then use that information to build management tools, localized market strategies and smarter networks to incentivize the highest-value care.

It’s outcomes-based utilization management that enables health plans to become the network of choice while unleashing data and insights to continuously improve member and provider satisfaction.

Precision UM represents a movement to a true value-based care system, connecting the systems necessary to align payments to outcomes and evolve beyond prior authorization of yesterday.

It’s possible. It’s proven. It’s Utilization Management Transformation with Olive.

Hear from Dr. Jeremy Friese, president of payer market at Olive, about how Olive is paving the way to connect both sides of healthcare's fax machine.