# Utilization Management * **Definition:** A process used by healthcare organizations to evaluate the necessity, appropriateness, and efficiency of healthcare services, procedures, and facilities, often involving prior authorization and review of care provided. * **Taxonomy:** Healthcare Topics / Utilization Management ## News * Selected news on the topic of **Utilization Management**, for healthcare technology leaders * 1.9K news items are in the system for this topic * Posts have been filtered for tech and healthcare-related keywords | Date | Title | Source | | --- | --- | --- | | 5/27/2025 | [**How health systems are tackling 2025's biggest supply chain challenges**](https://www.beckershospitalreview.com/supply-chain/how-health-systems-are-tackling-2025s-biggest-supply-chain-challenges/) | [[Beckers Hospital Review]] | | 5/12/2025 | [**The Evolving Physician Advisor: From UM to Value-Based Care - HIT Consultant**](https://hitconsultant.net/2025/05/13/the-evolving-physician-advisor-from-um-to-value-based-care/) | [[HIT Consultant]] | | 4/25/2025 | [**How health systems are curbing pharmacy costs**](https://www.beckershospitalreview.com/uncategorized/how-health-systems-are-curbing-pharmacy-costs/) | [[Beckers Hospital Review]] | | 4/14/2025 | [**Rapid Expansion of Healthcare Outsourcing Market to Reach $662 Billion by 2028, Driven ...**](https://www.newswire.com/news/rapid-expansion-of-healthcare-outsourcing-market-to-reach-662-billion-22551235) | [[Newswire]] | | 4/14/2025 | [**Rapid Expansion of Healthcare Outsourcing Market to Reach $662 Billion by 2028, Driven ...**](https://finance.yahoo.com/news/rapid-expansion-healthcare-outsourcing-market-120000654.html) | [[Yahoo Finance]] | | 4/7/2025 | [**WNS-HealthHelp and Availity Join Forces to Transform Payer-Provider Collaboration**](https://www.morningstar.com/news/business-wire/20250402047149/wns-healthhelp-and-availity-join-forces-to-transform-payer-provider-collaboration) | [[Morningstar]] | | 4/7/2025 | [**WNS-HealthHelp and Availity Join Forces to Transform Payer-Provider Collaboration**](https://finance.yahoo.com/news/wns-healthhelp-availity-join-forces-161500739.html) | [[Yahoo Finance]] | | 3/14/2025 | [**Contributor: The Complexity Concern in Value-Based Care**](https://www.ajmc.com/view/contributor-the-complexity-concern-in-value-based-care) | [[AJMC]] | | 3/6/2025 | [**Latitude Health Launches AI-Native Utilization Management Solution**](https://hitconsultant.net/2025/03/06/latitude-health-launches-ai-native-utilization-management-solution/) | [[HIT Consultant]] | | 2/17/2025 | [**Availity 'Shifts Left' on Prior Authorizations at Vive - Yahoo Finance**](https://finance.yahoo.com/news/availity-shifts-left-prior-authorizations-130000554.html) | [[Yahoo Finance]] | | 1/24/2025 | [**Innovaccer Secures $275M in Series F to Scale its Healthcare Intelligence Cloud**](https://www.healthcareittoday.com/2025/01/24/innovaccer-secures-275m-in-series-f-to-scale-its-healthcare-intelligence-cloud/) | [[Healthcare IT Today]] | | 1/10/2025 | [**Innovaccer clinches $275M series F funding to build out AI, cloud capabilities**](https://www.fiercehealthcare.com/health-tech/innovaccer-clinches-275m-series-f-funding-build-out-ai-cloud-capabilities) | [[FierceHealthcare]] | | 1/10/2025 | [**Innovaccer clinches $275M series F funding to build out AI, cloud capabilities**](https://www.fiercehealthcare.com/health-tech/innovaccer-clinches-275m-series-f-funding-build-out-ai-cloud-capabilities?itm_source=parsely-api) | [[FierceHealthcare]] | | 1/9/2025 | [**Innovaccer Secures $275M in Series F to Scale its Healthcare Intelligence Cloud**](http://www.businesswire.com/news/siliconvalley/20250109241872/en/Innovaccer-Secures-275M-in-Series-F-to-Scale-its-Healthcare-Intelligence-Cloud) | [[Business Wire]] | | 1/3/2025 | [**Artificial Intelligence, Digital Tools and the Future of Healthcare**](https://www.cioreview.com/cxoinsight/artificial-intelligence-digital-tools-and-the-future-of-healthcare-nid-40679-cid-31.html) | [[CIO Review]] | | 12/4/2024 | [**Maximus Earns URAC Accreditation for Health Utilization Management in Clinical Reviews**](http://www.businesswire.com/news/home/20241204156562/en/Maximus-Earns-URAC-Accreditation-for-Health-Utilization-Management-in-Clinical-Reviews/?feedref=JjAwJuNHiystnCoBq_hl-Q-tiwWZwkcswR1UZtV7eGe24xL9TZOyQUMS3J72mJlQ7fxFuNFTHSunhvli30RlBNXya2izy9YOgHlBiZQk2LOzmn6JePCpHPCiYGaEx4DL1Rq8pNwkf3AarimpDzQGuQ==) | [[Business Wire]] | | 12/4/2024 | [**Maximus Earns URAC Accreditation for Health Utilization Management in Clinical Reviews**](http://www.businesswire.com/news/home/20241204156562/en/Maximus-Earns-URAC-Accreditation-for-Health-Utilization-Management-in-Clinical-Reviews/?feedref=JjAwJuNHiystnCoBq_hl-RLXHJgazfQJNuOVHefdHP-D8R-QU5o2AvY8bhI9uvWSD8DYIYv4TIC1g1u0AKcacnnViVjtb72bOP4-4nHK5ieT3WxPE8m_kWI77F87CseT) | [[Business Wire]] | | 11/8/2024 | [**Utilization Management and Physician Burnout**](https://www.ajmc.com/view/utilization-management-and-physician-burnout) | [[AJMC]] | | 11/7/2024 | [**Iodine Software Ranked #1 in Client Satisfaction for AI-powered Mid-Revenue Cycle ...**](https://www.newswire.com/news/iodine-software-ranked-1-in-client-satisfaction-for-ai-powered-mid-22449741) | [[Newswire]] | | 9/17/2024 | [**Survey: Payers, Providers Boosting IT Investments - Healthcare Innovation**](https://www.hcinnovationgroup.com/finance-revenue-cycle/health-it-market/news/55140397/survey-payers-providers-boosting-it-investments) | [[Healthcare Innovation]] | | 9/3/2024 | [**Enhancing Healthcare Efficiency with Utilization Management and Electronic Prior Authorization**](https://techbullion.com/enhancing-healthcare-efficiency-with-utilization-management-and-electronic-prior-authorization/) | techbullion.com | | 8/26/2024 | [**Itiliti Health & VirtualHealth Announce New HELIOS® + Itiliti Health SaaS Solution for Healthcare Payers**](http://www.businesswire.com/news/home/20240826265979/en/Itiliti-Health-VirtualHealth-Announce-New-HELIOS%C2%AE-Itiliti-Health-SaaS-Solution-for-Healthcare-Payers/?feedref=JjAwJuNHiystnCoBq_hl-Q-tiwWZwkcswR1UZtV7eGe24xL9TZOyQUMS3J72mJlQ7fxFuNFTHSunhvli30RlBNXya2izy9YOgHlBiZQk2LOzmn6JePCpHPCiYGaEx4DL1Rq8pNwkf3AarimpDzQGuQ==) | [[Business Wire]] | | 8/26/2024 | [**Itiliti Health & VirtualHealth Announce New HELIOS® + Itiliti Health SaaS Solution for Healthcare Payers**](http://www.businesswire.com/news/home/20240826265979/en/Itiliti-Health-VirtualHealth-Announce-New-HELIOS%C2%AE-Itiliti-Health-SaaS-Solution-for-Healthcare-Payers/?feedref=JjAwJuNHiystnCoBq_hl-RLXHJgazfQJNuOVHefdHP-D8R-QU5o2AvY8bhI9uvWSD8DYIYv4TIC1g1u0AKcacnnViVjtb72bOP4-4nHK5ieT3WxPE8m_kWI77F87CseT) | [[Business Wire]] | | 8/12/2024 | [**Health Plans, Inc. (HPI) Earns URAC Re-Accreditation in Health Utilization Management**](https://www.prweb.com/releases/health-plans-inc-hpi-earns-urac-re-accreditation-in-health-utilization-management-302217579.html) | [[PRWeb]] | | 8/12/2024 | [**Quantum Health Appoints Dr. Stanley Crittenden as New Chief Medical Officer**](http://www.businesswire.com/news/home/20240812304065/en/Quantum-Health-Appoints-Dr.-Stanley-Crittenden-as-New-Chief-Medical-Officer/?feedref=JjAwJuNHiystnCoBq_hl-Q-tiwWZwkcswR1UZtV7eGe24xL9TZOyQUMS3J72mJlQ7fxFuNFTHSunhvli30RlBNXya2izy9YOgHlBiZQk2LOzmn6JePCpHPCiYGaEx4DL1Rq8pNwkf3AarimpDzQGuQ==) | [[Business Wire]] | ## Topic Overview (Some LLM-derived content — please confirm with above primary sources) ### Key Players - **MCG Health**: A healthcare technology company that has partnered with the Case Management Institute to provide training in utilization management for nursing professionals. - **Maximus**: Achieved full URAC accreditation for Health Utilization Management, demonstrating commitment to quality care and patient safety. - **VirtualHealth**: A technology provider that has launched an integrated platform to streamline utilization management and ensure compliance with healthcare regulations. - **Agadia**: A leader in utilization management solutions, known for its PromptPA portal that connects healthcare organizations to a network of health plans and streamlines prior authorizations. - **Availity**: The largest real-time health information network in the U.S., focusing on enhancing Clinical Documentation Integrity (CDI) and Utilization Management (UM) within the healthcare revenue cycle. - **WNS-HealthHelp**: A digital-led business transformation company collaborating with Availity to enhance utilization management processes through AI-driven solutions. - **Itiliti Health**: Collaborated with VirtualHealth to enhance care management and utilization management processes through advanced automation. - **Capital Rx**: A pharmacy benefit management company that has achieved URAC reaccreditation for its commitment to high standards in utilization management. - **Quantum Health**: Provides a comprehensive range of clinical support services, including Utilization Management and Pharmacy programs. - **Shearwater Health**: Recognized for its utilization management services, focusing on innovative solutions and strategic partnerships to improve healthcare efficiency. - **MRG Health Inc.**: A digital healthcare management services company focused on chronic care management and social determinants of health. - **CapitalRx**: A pharmacy benefit management company that has achieved URAC reaccreditation and NCQA Accreditation in Utilization Management, emphasizing high-quality patient care. - **Iodine Software**: A leading vendor in mid-revenue cycle management, recognized for its AI-powered solutions in utilization management and clinical coding. - **Dane Street**: A healthcare organization recognized for its NCQA Accreditation in Utilization Management, emphasizing quality and timely healthcare outcomes. - **Latitude Health**: A San Francisco-based company that launched an AI-driven utilization management suite aimed at improving patient outcomes and reducing inefficiencies. - **Evolent**: A healthcare technology company that acquired Machinify's prior authorization and utilization management software to enhance its service offerings. - **VirtualHealth and Itiliti Health**: Collaborative partners that launched the HELIOS + Itiliti Health platform to streamline utilization management and compliance. - **Concert**: A company that provides clinical criteria and coding standards to enhance the prior authorization process. ### Partnerships and Collaborations - **WNS-HealthHelp and Availity**: This collaboration aims to streamline utilization management processes by integrating AI-driven clinical guidelines into Availity's Intelligent Utilization Management solution. - **MCG Health and the Case Management Institute**: Partnered to offer a CNE-credited course combining utilization management foundations with MCG training for nursing professionals. - **Availity and Iodine Software**: A strategic partnership aimed at enhancing Clinical Documentation Integrity (CDI) and Utilization Management (UM) within the healthcare revenue cycle. - **Evolent and Machinify**: Evolent acquired Machinify's software and team to enhance its utilization management capabilities. - **MultiCare and Xsolis**: Partnered to enhance efficiency in case reviews and denial management. - **Availity and Concert**: Collaborated to automate and digitize the prior authorization and payment processes for genetic tests. - **OSF HealthCare and Xsolis**: Collaborated to utilize data-driven analytics for aligning medical necessity decisions and reducing conflicts. - **Latitude Health and National Organizations**: Latitude Health is partnering with organizations serving over 2 million members to enhance its AI-driven utilization management capabilities. - **Vital Data Technology and Mid-State Health Network**: Partnered to implement predictive data models aimed at enhancing healthcare quality and timeliness. - **VirtualHealth and Itiliti Health**: Collaborated to launch the HELIOS + Itiliti Health platform aimed at streamlining utilization management and ensuring compliance with healthcare regulations. - **Humana and Evolent Health**: Expanded their partnership to streamline prior authorization processes for oncology services, improving patient access to care. - **CapitalRx and URAC**: CapitalRx achieved full URAC reaccreditation, demonstrating its commitment to high-quality patient care and operational excellence. - **RWJBarnabas Health and Wellsheet**: Partnered to enhance clinical workflows using machine learning algorithms. - **IntusCare**: Formed partnerships to enhance data integration and care coordination for complex senior populations. - **Agadia and Healthcare Organizations**: Agadia's PromptPA portal connects healthcare organizations to over 45 health plans, streamlining prior authorizations for nearly 100 million lives. - **PsychArmor and CareSource**: Collaboration to achieve Military & Veteran Ready Organization Certification. ### Innovations, Trends, and Initiatives - **AI in Utilization Management**: Health systems are increasingly leveraging AI to improve collaboration and streamline utilization management processes. - **Intelligent Utilization Management Solutions**: Availity's solution automates the authorization process, significantly reducing turnaround times and enhancing the overall experience for patients and providers. - **AI and Automation in Utilization Management**: Technologies like AI and automation are being leveraged to modernize prior authorization processes, reduce administrative burdens, and improve patient access to care. - **CMS Reforms**: The Centers for Medicare & Medicaid Services (CMS) is proposing new regulations to improve access and transparency in Medicare Advantage, focusing on utilization management. - **AI and Big Data in Utilization Management**: Sophia Humphreys discusses the transformative impact of AI and Big Data on cost reduction and operational efficiency. - **Prior Authorization API**: CMS has mandated the implementation of a Prior Authorization Application Programming Interface by 2027 to streamline prior authorization processes. - **CMS Interoperability and Prior Authorization Final Rule**: Introduced to improve the prior authorization process for Medicare Advantage, mandating timely decisions and transparency in denials. - **California AI Regulations**: New regulations in California require human oversight in utilization management processes, potentially impacting the efficiency gained through AI. - **Gold Carding**: A new concept allowing high-performing providers to bypass prior authorization for certain drugs, aiming to balance cost management with patient access. - **California's Senate Bill 1120**: Aims to limit the use of AI in utilization management, reflecting growing concerns about AI's role in healthcare. - **Remote Health Monitoring Platforms**: TMA Solutions' platform tracks vital signs and lifestyle factors, improving healthcare delivery. - **HELIOS + Itiliti Health Platform**: This platform aims to streamline care management and utilization management while ensuring compliance with evolving regulations. - **Innovaccer's AI Solutions**: Innovaccer is enhancing its AI-powered healthcare solutions to improve utilization management and clinical decision support. - **Electronic Prior Authorization (ePA)**: Automates the process of obtaining insurance approval for medications and treatments, reducing time and administrative burdens for healthcare providers. - **Maximus URAC Accreditation**: Recognizes excellence in clinical review criteria and compliance with national healthcare standards. - **HL7 FHIR and Clinical Quality Language (CQL)**: Technologies used by payers for efficient data exchange and streamlining prior authorization processes. ### Challenges and Concerns - **Denial Management**: Increased denial rates by commercial health plans have led to significant costs for hospitals, emphasizing the need for improved utilization management practices. - **Regulatory Compliance**: Healthcare organizations face challenges in adapting to evolving federal and state regulations regarding utilization management. - **Transparency in Utilization Management**: Concerns over the lack of transparency in utilization management tools, particularly regarding step therapy for oncology drugs. - **Need for Compliance and Efficiency**: Healthcare organizations are under pressure to comply with evolving regulations while also improving efficiency in utilization management processes. - **Administrative Burdens**: High denial rates linked to utilization management algorithms in Medicare Advantage plans have raised concerns about access to care. - **Evolving Guidelines**: Utilization Management teams struggle to keep up with evolving guidelines and regulations, particularly in genetic testing. - **Physician Burnout**: High administrative burdens from utilization management processes, such as prior authorization and step therapy, contribute to physician burnout and negatively impact patient care. - **Cybersecurity Threats**: The ransomware attack on UnitedHealth Group highlights vulnerabilities in healthcare IT systems that can disrupt utilization management processes. - **Prior Authorization Delays**: Stricter medical necessity criteria and excessive prior authorization requirements in Medicare Advantage plans lead to delays in patient care. - **Complexity of Prior Authorization**: Over 20% of claims in 2023 required prior authorization, complicating the claims process and increasing administrative burdens for providers. - **Discriminatory Bias**: State attorneys general have raised concerns about discriminatory bias in AI tools used for utilization management, leading to investigations. - **Prior Authorization Issues**: Healthcare providers face significant challenges with prior authorization processes, leading to frustrations and calls for regulatory audits. - **AI Misuse**: Concerns have been raised about the potential misuse of AI by insurers to deny necessary medical care, prompting calls for human oversight. - **Fraudulent Billing Practices**: Concerns regarding fraudulent billing in lab testing and telehealth services are prompting increased scrutiny and regulatory measures. - **Financial Pressures on Providers**: Many healthcare systems are severing ties with Medicare Advantage plans due to financial losses and patient care delays. - **Financial Burden of Healthcare**: The increasing financial burden of U.S. healthcare, particularly in prescription drug spending, necessitates cost control. - **Legacy Technology**: Payer organizations face challenges with legacy systems that hinder scalability and cost management. ## Related Topics [[Care Utilization]]