Health Plans

Placing members at the center: Why health plans should transform utilization management

By Vikas Garg, Anoop Tripathi, Vimbai Mudimu, Andrew Borenstein, and Kara Chung

Feb. 16, 2023 | Article | 4-minute read

Placing members at the center: Why health plans should transform utilization management

Imagine a future where your health plan’s utilization management team electronically processes thousands of prior authorization requests per day. As soon as they do, dashboards are automatically updated to inform leadership of outcomes, staff productivity and other valuable real-time insights. Leadership doesn’t have to analyze data in spreadsheets—with a simple click they can see all the information they need to evaluate their utilization management programs and identify areas for improvements.


This is just one example of the promise of utilization management’s future and it’s a transformation worth striving toward. As rising healthcare costs continue to affect stakeholders throughout the healthcare ecosystem, health plans are exploring how they can optimize their utilization management programs to better ensure patient safety and reduce unnecessary spending. They’re also aiming to use their talent more efficiently, as they play a critical role in ensuring a positive member experience.

Utilization management challenges and solutions

Most health plans spend hundreds of millions of dollars each year reviewing prior authorization requests, many of which are still submitted and processed manually. In 2019, two-thirds of the $305 million that health plans spent on prior authorization was related to manual processes. Even after committing these resources to utilization management, health plans often don’t have a way to measure the value and impact of their prior authorization programs. In other words, some plans are operating their programs blindly and are unable to quantify their effectiveness. This situation risks not only poor member and provider experiences, but even long-term negative clinical outcomes.


The current solutions to utilization management challenges consist of temporary, quick fixes that improve parts of the existing system without looking at the program holistically. Piecemeal technology tools from different vendors offer limited value and insights, especially because the data from each tool is incompatible. Additionally, these tools burden health plans with managing multiple platforms.

A holistic approach to utilization management

As health plans prepare to transform their utilization management programs, it’s imperative they adopt a holistic approach to implementing solutions that build the foundation for their prior authorization programs. This foundation hinges on tools that enable faster and easier processes and offer predictive and actionable insights. By implementing these solutions, health plans can limit losses and optimize their operations while prioritizing the needs of their providers and members.


To envision a truly transformational utilization management program, it’s important to think beyond the status quo and consider future possibilities. A forward-thinking utilization management program will have fully automated capabilities that remove much of the administrative burden for both providers and health plans. These capabilities will enable instant decision-making that can eliminate the delays to necessary medical care that members often find frustrating. A transformational utilization management program will also apply real-time analytics that increase the agility of decision-making and enable ongoing management for long-term improvements. Ultimately, the goal for health plans should be to create a utilization management program that improves provider and member experiences while avoiding unnecessary medical and administrative costs.


“With utilization management facing challenges stemming from swelling administrative burdens, policy updates and a lack of real-time communication, now is the time to disrupt the status quo,” said Dr. James L. Voiland, a longtime managed care executive and former chief clinical officer of CareSource, which automates utilization management programs. “The next few years will be an exciting period for early adopters that take a holistic approach to transforming their utilization management programs.”

3 ways to become a more member-centric health plan

Health plans can transform their utilization management programs by focusing on three key goals: to make processes like prior authorization easy, fast and transparent.


When thinking about business-to-consumer transformational companies that use advanced solutions, it becomes clear many keep their customers’ needs at the center of everything they do. Ride-sharing companies like Uber and Lyft have transformed the transportation industry by offering on-demand taxi services via their easy-to-use apps that allow users to track the location of their drivers. Amazon, which is famously known for delivering consumer goods in a short time span, gained their customers trust by using advanced solutions that enabled one-swipe ordering, shipping and delivery tracking, and fast and consistent customer service. By introducing transformational services, these companies have drastically improved and simplified the consumer experience.


Health plans should approach utilization management programs with the same spirit. The key to utilization management transformation is focusing on member-centric solutions that simplify the members’ experience through faster and easier processes, while increasing transparency wherever possible. Striving to become a more member-centric health plan shows members that there are people behind the utilization management program who truly care for the members’ health and wellbeing.


It’s exciting to envision a future where utilization management programs use end-to-end solutions to produce predictive and actionable insights while making processes like prior authorization faster, easier and more effective. The healthcare ecosystem is evolving, and transformational utilization management programs can create positive change for members, providers and health plans.

Add insights to your inbox

We’ll send you content you’ll want to read – and put to use.

About the author(s)