Traditionally, health plans and health systems have used classic utilization management tools, such as membership verification, benefit eligibility and prior authorization to hold costs in check. Such activities, while not always received warmly by facilities, providers or patients, served to highlight inappropriate and over-utilization. The rules, of course, may vary significantly depending on provider or geographic location regarding the practice of evidence-based medicine.

However, in light of COVID-19, the time has come to consider some alteration to the traditional process. There is a strong consensus that utilization will surge significantly now due to postponed elective surgeries, delayed preventative clinical visits, reduced resistance toward telemedicine as an alternative to onsite visits, and patients avoiding medical establishments out of fear. Some in the industry estimate the surge to be as much as 40% above pre-COVID-19 levels.

Given this likely scenario and the limited resources currently available, it may be prudent to focus on the more inappropriate or over-utilized medical practices being requested. This will require reliable data for effective determination.

For example, in our experience, health plans list multiple procedures, medications and conditions that require prior authorization (PA); some receive approval as often as 100% of the time. Thus, is the “juice worth the squeeze”? While it is reasonable to assume there is some benefit to the PA process, similar to traffic cop scanning for speeders, current circumstances suggest these PA lists be revised.

For those concerned that utilization might spike in the absence of the PA, an audit process could be instituted allowing justifiable cases to be added back in. In the meantime, data can help identify which procedures, medications and conditions are most suitable for removal from the PA list.

Another potential opportunity to adjust the process is to consider “gold carding” some providers. Within the delivery system, solid data can identify those advanced registered practice nurses, physicians’ assistants, and medical doctors that almost always pass medical necessity review. How much is gained by forcing them into the medical necessity process, and could the limited resources be better invested on more problematic providers?

By gold carding preferred providers, and automatically approving all of their requests, provider relations and patient satisfaction could be improved. Then, if there is a concern about whether gold carding might open the flood gates to inappropriate or over-utilized practices, a periodic audit could validate whether such concerns are real and, if so, the gold card could be revoked.

As the COVID-19 challenge persists, expense and utilization trends will most likely rise. Now is the time to entertain new approaches in utilization management. To do so with confidence will require consistent and accurate data at hand. Working with business partners that have proven experience in the application of industry-specific data strategies and technologies will be a critical element in any successful utilization management reform.

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