Automating Utilization Management to Increase Auto Approval Rates for Contracted Provider Groups
Project Insight
Utilization Management Processing Automation
Our client processed utilization management referrals for contracted provider groups across a variety of geographies and products (Commercial HMO, Medicaid and Medicare Advantage). Variation within provider groups and complexity in product requirements led to slow processing rates and frustrated patients and providers.
Solution Implementation
We worked with the organization to rework their utilization management process from the ground up, streamlining submissions, processing rules, elevating provider privileges and identifying opportunities for continuous improvement:
Submission Process: Implemented an online system to streamline initial referral requests, submission of supporting documentation and processing status updates with customized rules for provider types and experience level.
Auto Processing: Developed automated processes and QA reporting necessary to update status for providers, link claims records and pre-approval for certain procedures.
Advanced Analytics: Developed advanced audit and process reports to identify opportunities for continuous improvement and future UM automation.
Results
The deployment of the system drastically improved the timeliness of approvals, improved provider and patient satisfaction and supported significant growth at a lower headcount ratios:
Timeliness Rate: Improved 200%+ over a 4-month period.
Enhanced Efficiency: The increase in auto approval rates allowed UM volume to increase significantly with minimal headcount increases. QA audit team was able to maintain compliance review ratios with the same headcount.
This case study highlights our expertise in streamlining UM processes and developing systems that support automated approvals. Through process improvement, automation and advanced analytics we improved operational decision-making, improved satisfaction of key stakeholders and improved efficiencies within a highly compensated workforce.
Domain & Technology
- UM medical necessity algorithms
- Real-time data integration
- Process automation tools
- Machine learning and advance analytics
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