The Utilization Management (UM) Regulation Domino Effect

The Utilization Management (UM) landscape is experiencing heightened regulatory scrutiny, particularly concerning prior authorization practices, exemplified by the upcoming Interoperability & Prior Authorization Final Rule (CMS-0057-F). This focus stems from concerns of delayed access to care and the administrative burden involved. However, prior authorization is just one piece of the broader UM value chain.

A single regulatory shift, such as the Colorado Bill to Strengthen Insurance Appeals (CO HB23-1201), can create a cascading "domino effect" across the entire UM value chain. To thrive in this increasingly complex regulatory environment, healthcare organizations need a strategic, organization-wide approach that emphasizes operational readiness and cross-functional alignment.

Discover how embracing a comprehensive approach to UM operations can not only improve compliance but also help reduce the total cost of care, foster greater affordability and sustainability. Moving beyond reactive, compliance-driven approaches allow healthcare payers to turn regulatory requirements into catalysts for broader operational transformation and strengthening readiness for future changes.