The next frontier in utilization management

The healthcare landscape is rapidly evolving, and Utilization Management (UM) strategies must adapt to meet new challenges and expectations. Current UM processes face significant challenges, including evolving federal and state regulations, unwarranted delays in care, increasing provider abrasion, and unsustainable operational costs. To address these issues, payors should transform UM into a more precise and specialized function that prevents fraud, waste, and abuse while supporting clinical decision-making.

This paper identifies three key value pools essential for future readiness: Technology Modernization through AI and automation, Delivery Model Enhancement through global approaches and localized strategies, and Reimagining UM through Alternative Payment Models (APMs) and Care Management (CM). By leveraging AI, automation, and innovative delivery models, payors can enhance operational efficiency, improve member and provider interactions, and drive scalability. The integration of APMs and CM can also help shift UM from a reactive to a proactive process, focusing on preventive care and reducing unnecessary utilization.