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What are the latest trends in utilization review processes?

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Utilization review (UR) is the process of evaluating the appropriateness, necessity, and quality of health care services and procedures. UR aims to improve patient outcomes, reduce costs, and ensure compliance with regulations and standards. In the context of healthcare management, UR is a vital function that involves multiple stakeholders, such as providers, payers, regulators, and patients. As the healthcare industry evolves, so do the trends and challenges in UR processes. Here are some of the latest developments that are shaping the future of UR.

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Jan Beger

Global Head of AI Advocacy @ GE HealthCare
Shayan Fatima

Medico-Marketer | Public Health | Digital Health Advocate | Medical Educationist | Healthcare Transformer | Corporate…
Mazin Ahmed

Healthcare and Development Leader | Public Health Program Manager at The Carter Center | Driving Impactful Health &…

1 Automation and AI

One of the most prominent trends in UR is the increasing use of automation and artificial intelligence (AI) to streamline and enhance the process. Automation and AI can help reduce manual tasks, improve accuracy, speed up decision making, and provide data-driven insights. For example, some UR platforms use natural language processing (NLP) to analyze clinical documentation and generate recommendations for authorization, denial, or referral. Other platforms use machine learning (ML) to identify patterns and anomalies in claims data and flag potential fraud, waste, or abuse. Automation and AI can also improve communication and collaboration among UR stakeholders, such as by providing chatbots, alerts, and notifications.

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Jan Beger

Global Head of AI Advocacy @ GE HealthCare
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AI in Utilization Management (UM) enhances efficiency and accuracy. In Prior Authorization, it evaluates the appropriateness of procedures against set criteria. In Concurrent Review, AI assesses ongoing patient care, ensuring alignment with best practices and identifying case or disease management strategies. In Retrospective Review, it helps verify post-care services’ coding accuracy and appropriateness. AI facilitates real-time communication, supports data-driven decisions, and improves care coordination and quality in UM processes.

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Shayan Fatima

Medico-Marketer | Public Health | Digital Health Advocate | Medical Educationist | Healthcare Transformer | Corporate Communications | Business Growth Enthusiast | BLS Trainer |
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The integration of automation and AI into utilization review processes enhances: - decision-making - improves efficiency - supports the delivery of high-quality cost-effective healthcare services.

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2 Patient-Centered Care

Another trend in UR is the shift towards patient-centered care, which focuses on the needs, preferences, and values of the individual patient. Patient-centered care aims to improve patient satisfaction, engagement, and loyalty, as well as health outcomes and quality of life. In UR, patient-centered care means involving the patient in the decision-making process, providing personalized and holistic care plans, and ensuring transparency and accountability. For example, some UR platforms allow patients to access their own UR information, provide feedback, and appeal decisions. Other platforms use patient-reported outcomes (PROs) and patient-generated health data (PGHD) to monitor and evaluate the effectiveness and impact of care.

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Shayan Fatima

Medico-Marketer | Public Health | Digital Health Advocate | Medical Educationist | Healthcare Transformer | Corporate Communications | Business Growth Enthusiast | BLS Trainer |
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Patient-centered care places the patient at the center of the care experience, fostering a partnership between patients and providers based on mutual respect, collaboration, and empathy. By prioritizing patients' needs and preferences, healthcare organizations can deliver more effective, satisfying, and patient-centered care experiences.

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Mazin Ahmed

Healthcare and Development Leader | Public Health Program Manager at The Carter Center | Driving Impactful Health & Development Initiatives
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In my experience, for the UR process to be patient-centered and involve the patients in the decision-making process, the patient's good orientation and in-depth knowledge of his/her health status will make a massive difference in the intended results.

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Jan Beger

Global Head of AI Advocacy @ GE HealthCare
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Adding to this, technology plays a pivotal role in advancing patient-centered care in UR. Telehealth services and digital health platforms enhance patient access to care and improve communication among providers, patients, and UR professionals. These technologies support real-time data sharing, enabling dynamic and responsive UR processes that adapt to each patient’s unique needs and circumstances. Moreover, leveraging predictive analytics and artificial intelligence in UR can help in proactive decision-making, identifying potential issues and optimizing care paths before they escalate, ensuring that the patient receives timely and appropriate care.

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3 Value-Based Care

A related trend in UR is the transition from fee-for-service to value-based care, which rewards providers based on the quality and efficiency of care they deliver, rather than the volume and intensity of services they provide. Value-based care aims to align the incentives of providers, payers, and patients, and to promote better health outcomes, lower costs, and higher quality. In UR, value-based care means adopting evidence-based guidelines, standards, and protocols, as well as measuring and reporting on quality indicators, such as readmission rates, complication rates, and patient satisfaction scores. For example, some UR platforms use clinical pathways, decision support tools, and quality metrics to guide and evaluate the UR process.

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Jan Beger

Global Head of AI Advocacy @ GE HealthCare
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In a value-based care environment, UR processes must be flexible and continuously evolving. Ongoing education and training of UR professionals are crucial to stay updated with the latest evidence-based practices and quality standards. Additionally, UR programs should foster a culture of continuous improvement, regularly evaluating and refining their processes to ensure they are aligned with the dynamic landscape of healthcare standards, regulations, and patient needs. Collaborative partnerships with various stakeholders, including healthcare providers, payers, and patients, are also essential to garner diverse insights and optimize UR strategies for enhanced value-based outcomes.

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4 Telehealth and Remote Monitoring

Another trend in UR is the expansion of telehealth and remote monitoring, which enable providers to deliver care and services to patients at a distance, using technology such as phone, video, or mobile apps. Telehealth and remote monitoring can help increase access, convenience, and continuity of care, especially for rural, underserved, or vulnerable populations. They can also help reduce costs, travel time, and exposure to infections. In UR, telehealth and remote monitoring mean adapting and updating the UR criteria, policies, and procedures to reflect the changes in the delivery and reimbursement of care. For example, some UR platforms use telehealth and remote monitoring data to authorize, review, and audit care.

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Jan Beger

Global Head of AI Advocacy @ GE HealthCare
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As UR incorporates more telehealth and remote monitoring, the significance of data security and patient privacy becomes paramount. UR platforms must ensure that the transmission, storage, and analysis of patient data comply with regulatory standards such as HIPAA. This involves implementing robust cybersecurity measures and encryption protocols to safeguard sensitive patient information. Additionally, educating patients and healthcare providers on best practices for maintaining data security during virtual interactions is crucial. By prioritizing data security, UR can maintain trust and integrity in the expanded use of telehealth and remote monitoring services.

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5 Regulatory Compliance and Accreditation

A final trend in UR is the growing importance of regulatory compliance and accreditation, which ensure that UR processes meet the legal, ethical, and professional standards and expectations of the healthcare industry. Regulatory compliance and accreditation can help protect the rights and interests of UR stakeholders, as well as enhance the credibility and reputation of UR organizations. In UR, regulatory compliance and accreditation mean following the rules and guidelines of various entities, such as the Centers for Medicare and Medicaid Services (CMS), the Joint Commission, and the Utilization Review Accreditation Commission (URAC). For example, some UR platforms use compliance and accreditation checklists, audits, and reports to monitor and improve the UR process.

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6 Here’s what else to consider

This is a space to share examples, stories, or insights that don’t fit into any of the previous sections. What else would you like to add?

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What are the latest trends in utilization review processes?

1

2

3

4

5

6

1 Automation and AI

2 Patient-Centered Care

3 Value-Based Care

4 Telehealth and Remote Monitoring

5 Regulatory Compliance and Accreditation

6 Here’s what else to consider

Healthcare Management

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What are the latest trends in utilization review processes?

1

2

3

4

5

6

1 Automation and AI

2 Patient-Centered Care

3 Value-Based Care

4 Telehealth and Remote Monitoring

5 Regulatory Compliance and Accreditation

6 Here’s what else to consider

Healthcare Management

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