New Study Reveals Need for Increased Transparency of Medical Management Determinations

March 4, 2016

Many health plans use utilization management (UM) programs as a cost containment measure to help control health care expenses along with ensuring that the right level of coverage is authorized for patients. After identifying a gap in the availability of information focusing on UM regulations and market trends, RegQuest formed a research team to draft the Utilization Management Regulatory & Market Trends: 2016 Annual Report. The report is the first update on the topic in over a decade and the research revealed several interesting trends pertaining to UM. Specifically, the need for more transparency and disclosure in how medical necessity decisions are made, came to light.

“Many aspects of the utilization management industry are undergoing tremendous changes and innovation,” states David Nixon, CEO of InformedDNA. “More ‘high-touch’ utilization management programs that cover genomics and molecular aspects of medicine is but one example where greater fidelity is required when making coverage determinations.” Mr. Nixon is one of the experts interviewed by the research team for the annual report.

The study found that the lack of transparency underpinning UM criteria has made it more difficult for regulators to track potential abuses of the system, and other errors. Consumer and legal advocates are raising concerns about the lack of transparency and accountability of “adverse benefit denials.” Because of the complexity of the appeals process, advocates are concerned that health plans, insurers, UMOs, TPAs, and others can functionally deny care and hide behind the complexity of the UM process.

The complexity of the process, coupled with a lack of information sharing, has also made it difficult to compare various UM processes and to gather an understanding of the return of investment associated with UM practices.

The RegQuest research team hopes that the Utilization Management Regulatory & Market Trends: 2016 Annual Report will not only serve as a helpful guide to navigate this complex regulatory environment, but that it will also stimulate public policy debate to identify best practices in terms of compliance with regulatory requirements and updates to key medical management practices by payers.

Although the report is only available to subscribers of RegQuest’s UM module, a complimentary primer is available. To check it out, please click here. If you would like to view the 62-page comprehensive report, sign-up for our UM Module! In addition to the UM Trend Report, you will also have access to our database of UM state laws and regulations, quick-reference tables and real-time updates regarding changes to legislation. For more information, please