Leveraging GenAI for Utilization Management

Imagine a world where healthcare providers are overwhelmed with paperwork, patients face endless delays for critical treatments, and the cost of care continues to skyrocket. Horrific, isn’t it? Well, this scenario isn’t far from reality if utilization management is neglected. Things like inefficient use of resources, redundant procedures, and administrative chaos can cripple any healthcare system.

In this blog, I’m going to help you understand everything about utilization management in healthcare, its importance, and its types. Moreover, I will provide insights to help your organization effectively navigate different strategies to implement utilization management, with a special focus on how Generative Artificial Intelligence (GenAI) can play a crucial role in this endeavor.

So, let’s get started!

What is Utilization Management?

In simple words, utilization management is a process to manage healthcare resources by evaluating its effectiveness, efficiency and medical necessity, according to established criteria and guidelines. The primary goals of utilization management are to optimize patient outcomes, control costs, and ensure that patients receive the right care at the right time.

The following diagram divides the strategies of utilization management into three types:

Fig 1: Strategies to perform utilization management

Let me narrow down the advantages of utilization management for you next!

Why is it essential to integrate utilization management into your system?

With utilization management integrated into your healthcare system, you’ll effortlessly achieve these:

1. Achieve satisfactory patient outcomes by reducing low value care provision and increasing high value care service provision.
2. Reduce fraud, abuse and waste of healthcare resources to optimize healthcare costs.
3. The above-mentioned two points will fulfill the third one, that is – boosting member satisfaction through timely access to effective and efficient care.

In addition to these, it will help health plans to achieve the following if these right strategies are being followed:

a) Reduce claim denials & improve patient care: This can be accomplished by implementing prospective and concurrent reviews. Follow these 2 steps:

• Automate effective prior authorization process
• Implementing evidence based clinical guidelines

This helps to save payer and provider’s time by minimizing repetitive administrative workflows.

b) Achieve Cost containment: Implementing prospective concurrent and retrospective utilization with the following strategies:

• Incentive Program: Offer incentives to providers based on their quality metric scores.
• Patient Education: Provide education to high-risk patients or target populations to achieve desired health outcomes. Utilization management analysis helps identify these patients and develop educational guidelines based on retrospective clinical and claims data analysis.
• Rewards System: Reward both members and providers for optimizing the use of cost-effective services.
• Provider Contracts: Establish contracts with high-performing providers based on their quality metric scores.

Now let’s understand the impact of AI when integrated with utilization management.

Keep reading! How GenAI Transforms Utilization Management?

How GenAI Transforms Utilization Management?

As the healthcare industry faces challenges such as rising costs, increasing patient expectations, and the demand for better patient outcomes, GenAI emerges as a transformative solution.

Here are a few problems that the healthcare ecosystem faced when it came to utilization management before the introduction of AI/GenAI:

Comprehensive documentation for the review process diverted medical staff away from their primary job of patient care, creating a significant burden.

• Long waiting for prior authorization process due to repetition of few administrative workflow.
• Review criteria were often hidden from healthcare providers and patients, preventing them from understanding the reasons for denial.

To minimize such challenges, solutions based on AI technologies like Machine learning, Deep Learning, Natural Language Processing (NLP), Robotic Process Automation came to the rescue.

The diagram below represents the impact of AI when integrated into various utilization management strategies:

Fig 2: AI in utilization management

As we near the end of this blog, I’d encourage you to read our success stories, showcasing how we have assisted numerous clients with effective utilization management.

How did we transform utilization management for our clients?

Leveraging our expertise in GenAI, deep learning, machine learning, natural language processing, large advance healthcare analysis, interoperability and integration, we have successfully delivered multiple groundbreaking solutions in utilization management. These innovations have proven to be game changers, enhancing patient care and reducing unnecessary healthcare costs.

Out of those, here are a few recently implemented solutions that I’d like to highlight:

1. Advanced tracking and early intervention for COVID-19:

   During the Covid-19 pandemic, we helped one of the leading payers by implementing prospective and concurrent review of utilization management to improve their member/patient health care and reduce cost by creating a COVID – 19 tracker. This helped to predict high risk patients and get the test done before time to avoid major complications. It also showed real time accurate number tracking for high-risk members, tested members, diagnosed, admitted, discharged and deceased patients.

2. Improved predictive solution to slash healthcare costs:

   For another major client, we tackled the issue of rising healthcare costs due to high readmission rates. By analyzing the root cause, our team developed a predictive solution that uses past claims and clinical data to forecast the risk of readmission for chronic disease patients. This approach, applied in both concurrent and retrospective utilization management, has helped the client save billions of dollars.

3. Enhanced population reports to optimize value-based care:

   We have also created a value-based care solution for utilization management to help key client to evaluate the quality of care in their utilization management’s retrospective review. Our experts did this by generating provider-centric and population health management-centric reports (that contain information like, provider scorecards, quality dashboards, potential preventable dashboards, etc.). This solution enhanced patient care, reduced costs, and motivated providers to use resources more efficiently by offering incentives for high-quality performance.

In a nutshell, utilization management into healthcare has abundant scope to reduce healthcare costs by reducing abuse, waste and fraud and by utilizing efficient healthcare resources to improve patient care.

To leverage these cutting-edge technologies and transform challenges into practical solutions, I highly recommend connecting with the Nitor Infotech team.

Elevate your healthcare management today with our AI technology!