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Trends and Changes in Utilization Management

Utilization management’s ability to perform efficient and effective medical necessity reviews have been enhanced by a variety of technological and process improvements.  This article will cover a number of the more significant changes and trends in these areas, including technological advancements, trends toward utilization of physician advisors, and the concepts of predictive analytics and artificial intelligence (AI), which will continue to provide additional benefits for the review process.

The most notable technological advancement that has simplified the medical necessity review process has been the transition to the fully electronic health record (EHR).  This transformation has allowed for a broader view on a patient’s care. The EHR has enabled information to follow the patient by electronic data transmission, whereas before information resided within one fixed location, or was kept, scattered, in several locations. This is a vast improvement over previous methods such as faxing and hybrid medical records.

Another positive change that has helped the review process has been the around-the-clock staffing of case managers in the Emergency Department. When patients are assessed by a case manager in the Emergency Department instead of retrospectively after the admission has taken place, they are more likely to be admitted to the appropriate level of care. In addition, we have seen this practice lead to significant reductions with denials. 

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The introduction of physician advisors and clinical documentation improvement (CDI) specialists into the utilization review process has also led to significant performance improvement.  The inclusion of physicians within case management teams aids in the accurate determination of medical necessity, as they provide valuable clinical judgment on optimal patient placement.  Clinical documentation improvement (CDI) specialists can be a great resource for physicians, physician advisors and utilization management reviewers.  Specialists can assist and add value by providing clinical teams with the tools necessary to provide proper documentation.  Incorporating CDI and physician advisors into the mix can significantly reduce denials related to inadequate or incomplete physician documentation.

In coming years, the utilization review process will be further enhanced by predictive analytics and artificial intelligence (AI).  Predictive analytics include the data and machine learning algorithms that predict the likelihood of future outcomes based on past data.  Being alerted to potential situations in advance allows for greater understanding when making difficult determinations and decisions.  Predictive analytics can also be useful in identifying patients who are likely to incur higher medical utilization in the future by analyzing claims data.  This insight will be valuable in creating targeting strategies to reduce healthcare expenditures.

Artificial intelligence will be able to assist in gathering data for medical necessity determinations.  AI will be able to process large amounts of data, recognize patterns in that data and learn from itself (the core of machine learning).  AI can benefit the utilization management process in several ways.  AI can reduce the amount of time spent on first-level reviews by stratifying initial cases.  It can also assist physician advisors in decision making by accessing the most current research and highlighting pertinent information.  This in turn saves time, improves accuracy and has the potential to reduce denials.

An effective Utilization Management program is crucial to ensuring high quality, cost-effective care, leading to a decrease in denial rates, as well as a reduction in healthcare costs in general. These trends and changes toward automation allow us see the future of the medical necessity review process, one that is more effective, efficient and accurate.

CBIZ offers a number of services utilization management services, such as appeals and denial management, and medical necessity reviews for inpatient and observation settings of care.

If you would like more information please contact Cynthia Raymond at 609-918-0990 or

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