UM Touches Nearly Every Care Decision, Yet It’s Widely Misunderstood

Utilization management shapes nearly every significant care decision made in U.S. healthcare, yet it remains one of the least understood functions in the system, often reduced in shorthand to “the prior auth department.” That framing was already too narrow when the Institute of Medicine (IOM) first studied the field in 1989, and it’s even less accurate now.

Two forces make this the moment to understand UM more precisely. New CMS operational requirements take effect January 1, 2026, under the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F). And physician sentiment has become impossible to ignore: in the 2025 AMA Prior Authorization Physician Survey, 95% of physicians say prior authorization processes delay access to necessary care.

UM began as a cost-containment tool. The programs that hold up under regulatory and clinical scrutiny today are the ones that have evolved into a clinical quality discipline instead.

What Is Utilization Management?

The field’s standard definition comes from the Institute of Medicine’s 1989 report: techniques used by, or on behalf of, purchasers of health benefits to manage costs by influencing care decisions through case-by-case assessment of appropriateness.

In practice, that plays out across three review windows: prospective review (prior authorization), concurrent review, and retrospective review, backed by peer review, appeals, and independent or external review as the system’s checks on any single determination. Prior authorization is one component of UM, working as a clinical quality tool applied before care is delivered, not a standalone product or a cost-cutting mechanism on its own.

Where Did Utilization Management Come From?

UM’s roots trace to the mid-1960s and 1970s, when Medicare and Medicaid created formal utilization review processes, and Congress established Professional Standards Review Organizations in 1972 to evaluate medical necessity with peer-review boards of care delivered through federal healthcare programs. Through the 1980s, employers and insurers adopted utilization review widely as health costs climbed, and UM grew into a private-sector industry.

The IOM’s 1989 report gave the field a definition, legitimacy, and its first serious quality critique. The managed care backlash of the 1990s followed, and accreditation bodies including URAC and the National Committee for Quality Assurance (NCQA), emerged to standardize review quality and independence. Evidence-based clinical criteria matured through the 2000s and 2010s as external review rights expanded under state law and the Affordable Care Act. The 2020s have brought a wave of regulatory modernization: electronic prior authorization, mandated turnaround times, transparency reporting, and state-level reform, culminating in CMS-0057-F.

What Makes a Utilization Management Program High-Quality?

Not all UM programs are built the same, and the gap between a strong program and a weak one shows up in five places.

Evidence-based criteria, applied consistently. Determinations should be grounded in current clinical literature, not blanket rules applied without regard to the individual case. URAC’s accreditation standards build consistency and evidence-based practice into the review process itself.

The right reviewer for the case. Quality review means same-specialty physician review, and, where required, review by a physician licensed in the same state as the patient, per URAC’s standards.

Speed as a quality metric, not just an operational one. Turnaround time is now a compliance requirement. The guidelines under CMS-0057-F set a 72-hour standard for expedited requests and 7 calendar days for standard requests.

Independence and conflict-of-interest safeguards. No incentive should be tied to determination outcomes. That independence is the premise behind the independent review organization model and behind URAC’s dual accreditation structure.

Transparency in the decision and the path to challenge it. Every determination needs a specific, transparent reason and a meaningful appeals path, with peer-to-peer dialogue available in place of one-way adjudication. CMS-0057-F formalizes several of these requirements for impacted payers.

What’s Changing in Utilization Management?

The operational provisions of CMS-0057-F took effect January 1, 2026: standardized decision timeframes, specific reasons required for adverse determinations, and public prior authorization metrics, with impacted payers’ first reports due March 31, 2026. Fast Healthcare Interoperability Resources (FHIR) API requirements and more are required by January 1, 2027.

States haven’t waited for federal action. A wave of states enacted prior authorization reform in 2024 and 2025, with more than a dozen in 2024 alone, and requirements now vary meaningfully by state on gold-carding, decision timelines, and transparency. Health plan leadership evaluating a UM partner should confirm the current state count against the AMA’s tracker before assuming uniform requirements across their footprint.

The industry has also made its own commitments. In June 2025, over 60 health insurers pledged to reforms including ensuring clinical denials get reviewed by a qualified clinician and expanding real-time responses. Physicians remain skeptical it will hold: the same 2025 AMA survey found only one in three physicians believe the pledge will make a meaningful difference, and just one in four believe medical-necessity denials are consistently reviewed by an appropriately qualified clinician today. Both data points are worth holding in mind at once: the commitments are real, and so is the skepticism about whether they’ll be honored in practice.

Technology’s role in UM is also shifting, though not in the direction some assume. The programs earning trust are using intake automation, criteria surfacing, and analytics to reduce unnecessary prior authorization volume, not to make determinations. Every one of those tech-enabled workflows still routes the actual decision to a physician reviewer.

For a health plan or TPA evaluating a UM partner in 2026, confirm these five criteria—regardless of state or line of business:

• Evidence-based criteria, applied consistently
• Specialty-matched physician review
• Accreditation through URAC or NCQA
• Measured and reported turnaround time
• Peer-to-peer dialogue available
• Analytics designed to reduce review volume, not increase throughput

How MRIoA Approaches Clinical Review

Medical Review Institute of America (MRIoA) has operated as a clinically driven utilization management partner since 1983. That 40-plus year track record is backed by URAC dual accreditation across Health Utilization Management and Independent Review Organization, plus NCQA accreditation, a network of 700-plus state-matched specialists across 150-plus specialties, and licensure in all 50 states.

Every case is matched to a same-specialty physician reviewer, with MRIoA’s technology streamlining intake and workflow so that reviewers can focus on the clinical judgment only they can provide. On MRIoA’s own reviews, that structure supports 98%+ turnaround-time performance, 99%+ quality performance, and more than 2.4 million reviews completed per year.

UM’s 40-year history is really the industry learning, sometimes the hard way, that cost and quality aren’t competing goals when reviews are clinically led. Health plans and at-risk providers evaluating a UM partner can talk with MRIoA’s clinical review team about benchmarking their UM program against the standard outlined above.

Talk with MRIoA’s clinical review team about your UM program. Click here to learn more.

Frequently Asked Questions

What is utilization management in healthcare?

Utilization management is the set of clinical review processes payers use to confirm that requested care is medically necessary and appropriate. It includes prospective review (prior authorization), concurrent review, and retrospective review, anchored to the IOM’s 1989 definition of the field.

What are the three types of utilization review?

Prospective review happens before care is delivered and includes prior authorization. Concurrent review happens during an ongoing course of care, such as an inpatient stay. Retrospective review happens after care has been delivered, evaluating appropriateness after the fact.

Is prior authorization the same as utilization management?

No. Prior authorization is one prospective component of UM, not the whole discipline. UM also includes concurrent and retrospective review, plus peer review, appeals, and independent or external review.

What does “medical necessity” mean in a clinical review?

A determination that a requested service is appropriate for the patient’s condition based on current clinical evidence, assessed case by case rather than through a blanket rule. Quality reviews apply this standard through same-specialty physician judgment, not automated criteria alone.

What makes a utilization management program high-quality?

Evidence-based criteria applied consistently, specialty-matched physician review, independence from outcome-based incentives, measured turnaround time, and transparency in both the determination and the appeals path.

What are the CMS prior authorization requirements for 2026?

Under CMS-0057-F, impacted payers must decide expedited requests within 72 hours and standard requests within 7 calendar days, provide specific reasons for adverse determinations, and publicly report prior authorization metrics, with first reports due March 31, 2026.

The post The Evolution of Utilization Management: From Cost Containment to Clinical Quality appeared first on MRIoA.

Public reporting requirements reveal what happens without that discipline. A January 2026 KFF analysis found that Medicare Advantage insurers made nearly 53 million prior authorization determinations in 2024, and 80.7% of appealed denials were partially or fully overturned, a pattern consistent since 2019. A June 2026 HHS OIG report found 95% of appealed skilled nursing facility denials overturned, language OIG itself used to say this “raises concerns” about the initial determinations.

Review quality is the variable that determines whether UM functions as a clinical quality tool or a source of rework, provider abrasion, and regulatory exposure.

What Quality Actually Means in a Clinical Review

“Quality” gets used loosely in UM. Measured precisely, it comes down to four dimensions: the right reviewer, current evidence, first-pass accuracy, and defensible documentation.

The reviewer-match gap is where the industry’s own data is most uncomfortable. In the 2025 AMA Prior Authorization Physician Survey, only 24% of physicians say medical-necessity denials are consistently reviewed by a licensed, qualified clinician, and just 16% say the health plan representative in a peer-to-peer review often or always has the appropriate credentials. The full survey data breaks this down further by specialty and line of business.

First-pass accuracy is what overturn rates, reviewer consistency, and audit scores are actually measuring, and it’s built into accreditation for a reason: URAC’s utilization review standards set the timeframe and process expectations that a defensible review has to meet. Worth noting for a full picture, not just a favorable one: KFF’s own analysis points out that high overturn rates can also reflect incomplete documentation at the initial request, not only reviewer error. That’s a reason complete information capture belongs inside the definition of quality, not outside it.

What Members Gain When the Review Is Right the First Time

An overturned appeal represents care a provider already ordered and a plan later agreed was necessary, just delayed by the extra step of appealing it, as KFF frames it. That delay isn’t neutral. In the 2025 AMA survey, more than 1 in 4 physicians reported that prior authorization led to a serious adverse event for a patient in their care.

Quality protects members in both directions at once: confirming that requested care is evidence-based and appropriate, which is what prior authorization is designed to do as a clinical quality tool, and confirming that appropriate care isn’t needlessly delayed by a review that gets it wrong the first time. Getting both of those directions right, consistently, is what a health plan owes the members whose care depends on the decision.

What Providers Gain: A Peer Worth Talking To

Provider abrasion around prior authorization usually gets treated as a network relations problem. It’s more accurately a quality symptom. Physicians report completing 40 prior authorizations per week on average, and 94% say PA contributes to burnout, according to the AMA. Underneath the volume, the skepticism is specifically about who’s on the other end of the review.

Specialty matching is the structural fix. When peer-to-peer review means a same-specialty physician talking to another physician, the conversation functions as clinical dialogue instead of an obstacle to route around, and a determination that redirects care to a more appropriate option keeps its credibility with the ordering provider. Fewer resubmissions and escalations follow from that one upstream decision: who reviews the case in the first place.

The Economics: You Pay for Review Quality Either Way

A low-quality determination gets paid for three times:

• Once in the original review
• Again in the appeal it triggers
• Third time in downstream exposure

For CMS-0057-F payers, public reporting makes the first two visible to regulators, providers, and members directly; plans outside that scope don’t face public disclosure, but the underlying costs still show up in appeal volume and provider relationships. The third is easy to overlook in a procurement decision built around unit price: KFF’s analysis of post-acute care denials notes that independent review entity reversals can negatively affect a plan’s star ratings.

A quality evaluation looks at what predicts first-pass accuracy before a single case is reviewed:

• URAC or NCQA accreditation
• Depth of a specialty-matched physician panel, all-state licensure
• Documented, audited quality program the partner is willing to show you

How MRIoA Builds Quality Into Every Review

MRIoA has operated as a clinically driven utilization management partner for more than 40 years, built specifically around the reviewer-match and first-pass-accuracy dimensions of quality described in this article. That track record is backed by URAC dual accreditation across Health Utilization Management and Independent Review Organization, NCQA accreditation, HITRUST certification, a network of 700-plus state-matched physician specialists across 150-plus specialties, and licensure in all 50 states.

MRIoA’s tech-enabled workflows streamline intake and case routing, with every determination made by a physician reviewer matched to the case. That structure supports 99%+ quality and 98%+ turnaround-time performance across more than 2.4 million reviews per year, the kind of first-pass accuracy that keeps a plan off the overturn-rate scoreboard rather than on it.

A Midwest Blue Cross Blue Shield plan partnered with MRIoA to eliminate a sizeable medical director review backlog while sustaining more than 98% quality and turnaround-time performance throughout. Health plans, TPAs, and PBMs evaluating a UM partner’s quality program are welcome to schedule a consultation with MRIoA’s clinical review team to benchmark their program’s quality metrics against that standard.

The post Quality in Clinical Review: The UM Metric That Pays for Itself appeared first on MRIoA.

A 14-year-old with high-functioning autism spectrum disorder (ASD) is denied 15 hours.

Both determinations could be wrong.

Medical directors understand this juxtaposition: autism-related utilization management (UM) is a lose-lose if you get it wrong in either direction. Deny too aggressively and you’re exposed to parity complaints, member grievances, and litigation. Approve everything without clinical scrutiny and you’re failing members who need the right services, not just more services. At the end of the day, neither outcome serves the member.

A practical path between these two failure modes exists, but it requires clinical precision at the review level, not policy reflexes applied at scale.

Why Autism UM Is Uniquely Hard to Calibrate

The challenge starts with the condition itself. The 4-year-old and the 14-year-old in our example above require different clinical reasoning, different intensity benchmarks, and different outcome measures — but both can land in the same review queue and be treated as variations of the same request. Autism is genuinely heterogeneous, and that heterogeneity is what makes this category of UM uniquely hard to calibrate.

Recent estimates from the CDC’s Autism and Developmental Disabilities Monitoring Network estimated ASD prevalence among 8-year-olds at 1 in 31 — and that number continues to increase, which means case volume is increasing with it.

Evidence-based intensity benchmarks exist, but they’re not settled. The Council of Autism Service Providers (CASP) standards of care call for 30 to 40 hours per week of direct ABA intervention for young children, sustained for at least two years. Yet the research on optimal dosage, age of intervention, and concurrent service combinations has been critiqued enough that the council published a white paper in 2025 specifically to counteract studies contesting its position on intensity.

That complexity runs deeper than hours per week. ABA is commonly misperceived as one practice when it’s actually a set of different intervention practices, and the appropriate combination varies by patient. UM criteria built for more uniform conditions don’t account for that variability well. Applied without clinical context, they produce false positives (approving low-value services) and false negatives (reducing necessary treatment) in roughly equal measure.

State autism mandates create an additional layer of complexity. Mandate language often sets floors on coverage but says little about clinical standards for appropriateness review. That gap leaves medical directors to calibrate on their own.

The Overutilization Side of the Equation

Any honest conversation about autism UM must acknowledge that inappropriate approvals are also harmful. A child receiving 40 hours of ABA per week when 20 would produce equivalent outcomes is not getting better care. The excess hours carry opportunity costs for the family, and they consume resources that could reach other members waiting for services.

The spending trajectory makes this concrete. North Carolina’s Medicaid payments for ABA went from $122 million in fiscal year 2022 to a projected $639 million in fiscal year 2026 — a 423% increase in four years. That growth is driven partly by rising prevalence and expanded coverage, but it also reflects a system where intensity decisions are not always individualized.

A 2025 survey reported in Behavioral Health Business found that 80% of board-certified behavior analysts report no formal training in determining service hours, a systemic training gap in one of the most consequential clinical decisions in ABA treatment planning.

Good UM supports appropriate treatment. Sometimes that means redirecting to a less intensive level of care. And when concurrent services are authorized without coordination, they can fragment care rather than strengthen it. Health plans have a legitimate clinical role in ensuring that services are coordinated and goal aligned.

Getting the Balance Right

What balance looks like at the review level comes down to five best practices.

1. Match reviewer credentials to case complexity. ABA and broader autism cases warrant developmental and behavioral pediatric expertise, not generalist review. Specialty-matched reviewers produce more accurate determinations in both directions because they understand the clinical rationale for a given intensity level — and they can identify when that rationale is missing.

2. Require individualized clinical rationale in every review, not criteria checkboxes. The review record should document why this member, at this developmental stage, does or doesn’t require this intensity. Generic rationale fails on appeal and fails the member.

3. Update criteria to reflect current evidence. If your plan’s ABA criteria haven’t been reviewed against current literature in the past two years, they’re likely out of date. Evidence-based criteria are a prerequisite for evidence-based decisions.

4. Treat concurrent service review as a coordination question rather than a duplication question. The default lens should be how these services work together for this member — not which one to remove.

5. Track denial overturn rates by condition and reviewer type. A high overturn rate on autism-related cases at external review is a signal that the internal review process needs recalibration, not that the criteria need to be tightened further.

Better Outcomes on Both Sides

Health plans that get autism UM right don’t choose between protecting their members and managing utilization appropriately. They achieve both by investing in clinical precision at the review level. The plans that struggle are applying standardized criteria to a condition that is anything but standard.

The difference starts with the reviewer. MRIoA’s network of 700+ state-matched specialists across 150+ specialties includes developmental and behavioral pediatric expertise for every case — where the right call depends on clinical context only a matched reviewer can provide.

Schedule a clinical review consultation to discuss how your autism UM program can deliver better outcomes.

The post The Right Call on Autism: How Health Plans Can Reduce Inappropriate Denials While Ensuring Appropriate Care appeared first on MRIoA.

That distinction seems obvious. In utilization management, it’s often ignored.

Rates of anxiety, depression, and behavioral disorders among children and adolescents have reached crisis levels, driving an unparalleled demand for care. Health plans are facing pressure to build efficient, integrated care models that move cases faster and reduce administrative burden.

Behavioral health is no exception to this pressure; however, pediatric psychiatry presents a specific and underappreciated strain. Developmental context, family systems, school and social factors, and medication protocols that don’t mirror adult standards aren’t edge cases. They’re the clinical reality of nearly every case in this population. Reviewing these cases requires more than operational efficiency. It requires subspecialty depth.

For most health plans, that depth is exactly what’s missing. In utilization management, subspecialty expertise in child and adolescent psychiatry isn’t an afterthought. It’s a clinical and operational imperative.

The Exponential Demand for Child and Adolescent Psychiatric Care

The scale of the problem is no longer debatable. In 2023, roughly 1 in 5 adolescents ages 12 to 17 had a current, diagnosed mental or behavioral health condition. Between 2016 and 2023, the prevalence of diagnosed mental or behavioral health conditions among adolescents increased by 35%, with diagnosed anxiety up by 61% and depression up by 45%. These aren’t post-pandemic anomalies. They’re a structural shift in the behavioral health needs of an entire generation.

Health plans, third-party administrators, and employers need to adjust to this shift in real time.

Among adolescents with a current diagnosis who needed treatment, 61% reported difficulty accessing it in 2023, a 35% increase since 2018. When the system can’t absorb that demand in outpatient settings, cases escalate into inpatient admissions, residential placements, partial hospitalization, and intensive outpatient requests, each requiring clinical review. Every gap in the community safety net becomes a case in a utilization queue.

Here’s what makes it harder than it looks on paper: A 13-year-old presenting with acute anxiety requires a different clinical lens than an adult with the same diagnosis. It needs to account for family dynamics, school environment, trauma history, and medication considerations that aren’t identical to adult protocols. The clinical variables are different, as are the level-of-care thresholds. The stakes are even higher because the downstream effects of a wrong review for a child in formative developmental years can be consequential.

Why Pediatric Psychiatric Cases Present Unique Review Challenges

Pediatric psychiatric cases are uniquely complex. A 15-year-old presenting with severe depression may also carry a trauma history, a learning disability, and a home environment that is actively destabilizing her recovery. Comorbidity is the norm in this population, and untangling it requires a reviewer who understands how these conditions interact developmentally.

The wide spectrum of cases reflects this complexity:

• Inpatient psychiatric admissions for suicidal ideation or suicide attempts
• Residential treatment center placements for youth with chronic behavioral or trauma-related conditions
• Partial hospitalization and intensive outpatient requests following acute episodes
• Extended stays beyond initial authorization, where continued stay criteria are particularly difficult to apply in adolescents
• Concurrent medical and psychiatric admissions requiring coordination across service lines
• Medication management reviews: Prior authorization for atypical antipsychotics, stimulants, mood stabilizers, and other psychotropics in pediatric populations, where dosing, off-label use, and developmental appropriateness add complexity
• Autism spectrum disorder (ASD) and co-occurring conditions: ABA therapy authorizations, as well as reviews involving ADHD, anxiety, mood disorders, and trauma presenting alongside ASD
• Eating disorders: Anorexia, bulimia, and ARFID in adolescents often require multi-setting review across medical and psychiatric levels of care, where medical necessity criteria can be difficult to apply without subspecialty knowledge
• Substance use and dual diagnosis: Reviews involving co-occurring substance use and psychiatric conditions, where treatment setting and duration decisions are especially high-stakes
• Extended or repeated acute episodes: Cases involving frequent readmissions or chronic high utilization that require clinical pattern recognition beyond standard criteria application

Creating the Capacity for Subspecialty Review

Generalist reviewers are skilled clinicians. The problem isn’t effort — it’s fit. Reviewing child and adolescent psychiatric cases requires a clinical frame that general behavioral health training doesn’t reliably provide.

When that fit is missing, the consequences are predictable: criteria applied technically but not clinically, denials that don’t hold up under challenge, peer-to-peer conversations that go poorly, and appeals that carry real costs in administrative time, legal exposure, and regulatory risk as federal and state parity enforcement has intensified.

The obvious solution is to build this capacity internally, but today’s workforce doesn’t support it. Child and adolescent psychiatrists are among the scarcest specialists in medicine, with severe shortages across the country. For most health plans, leveraging a credentialed subspecialty review partner is a viable option to filling that gap in expertise.

What to Look for in a Behavioral Health UM Partner

Not all review organizations are equipped for this population. When evaluating a partner, four criteria matter most:

1. A credentialed panel of child and adolescent psychiatrists. Board certification in child and adolescent psychiatry is a distinct credential, earned through additional training beyond general psychiatry.
2. Familiarity with pediatric-specific criteria. InterQual, MCG, and similar tools have pediatric modules, but applying them correctly requires clinical experience with this population, not just access to the tool. Ask how reviewers are trained on pediatric criteria and how that training is maintained.
3. Subspecialty peer-to-peer capability. When decisions are challenged, peer-to-peer conversations matter. That conversation should happen between clinical equals as the standard for producing defensible outcomes and supporting the treating relationship.
4. Turnaround times that don’t sacrifice rigor. Pediatric psychiatric cases, especially those involving acute safety concerns, require both speed and clinical depth. In the hands of an experienced subspecialty reviewer, these aren’t competing priorities.

Matching Review Expertise to the Complexity of the Case

The regulatory and operational pressure on health plans to get behavioral health reviews right the first time, every time is only intensifying.

Subspecialty expertise in child and adolescent psychiatry isn’t a feature to evaluate during the next contract cycle. It’s a gap that’s costing plans right now in appeals, in peer-to-peer losses, in regulatory exposure, and in outcomes for a population that has very little margin for error.

MRIoA’s panel of board-certified child and adolescent psychiatrists brings the subspecialty depth that pediatric psychiatric UM demands with the turnaround times, peer-to-peer capability, and criteria expertise to support defensible, clinically grounded decisions at every level of care.

The post Why Subspecialty Expertise Matters in Child and Adolescent Psychiatry Utilization Management appeared first on MRIoA.

In this on-demand webinar, CredibleMind and MRIoA explore how organizations can close this gap by helping individuals:

• Recognize early signs of need
• Understand their options
• Take the right next step before issues escalate

Watch the full Behavioral Health Webinar recording for a practical framework for improving how behavioral health needs are identified, triaged, and addressed across the full continuum of care. 

The post Closing the Behavioral Health Decision Gap Webinar Recap appeared first on MRIoA.

The emerging clinical consensus positions SUD alongside conditions like diabetes, hypertension, and heart disease: a chronic illness that requires ongoing medical management, evidence-based intervention, and coordinated care across multiple specialties. For health plans and TPAs, this reframing demands a parallel evolution in how UM programs evaluate appropriate levels of care. The gap between where SUD treatment is heading and how most UM programs are currently designed represents both a clinical risk and a financial one. 

The Gap Between SUD Care Reality and UM Practice 

The American Society of Addiction Medicine (ASAM) Criteria, 4th Edition (published December 2023), organizes SUD treatment into four broad levels of care: Level 1 (Outpatient), Level 2 (Intensive Outpatient), Level 3 (Residential), and Level 4 (Medically Managed Inpatient). Within each level, decimal gradations reflect increasing clinical intensity, with the medically managed sub-levels — 2.7, 3.7, and 4 — representing the points on the continuum where active withdrawal management and biomedical monitoring are required. Yet despite this well-established framework, UM programs often default to binary thinking: inpatient withdrawal management or not, residential or outpatient. 

The data illustrates both the scale and the shifting complexity of the challenge. According to the 2024 National Survey on Drug Use and Health (NSDUH), published by SAMHSA in July 2025, an estimated 48.4 million people in the U.S. — roughly 16.8% of the population aged 12 or older — met criteria for a substance use disorder in 2024. Yet 80% of those who needed treatment did not receive it. Among those who do enter the treatment system, the stakes of appropriate level of care placement are high. This is especially true as SUD presentations grow more medically complex: polysubstance use, alcohol-related hepatic disease, opioid use disorder with cardiac and pulmonary complications, and stimulant use with psychiatric comorbidities are increasingly common clinical presentations that demand more from UM review, not less. 

Health plans and TPAs face a dual risk when UM programs are not calibrated to this complexity: 

• Overutilization: Patients placed at higher levels of care than clinical evidence supports, driving avoidable inpatient costs and occupying limited beds needed by patients who genuinely require that level of care. 

• Underutilization: Patients stepped down prematurely without clinical basis, increasing the likelihood of relapse, readmission, and higher total cost of care over time. 

The regulatory landscape reinforces the need for rigor. While all U.S. states have enacted statutes addressing mental health and SUD insurance parity, the strength and scope of these laws vary widely. State insurance commissioners are increasingly scrutinizing how health plans apply UM criteria to behavioral health relative to medical and surgical benefits, and the data in the Mental Health and SUD Insurance Parity Summary of State Laws demonstrates that most states have enacted or are actively writing legislation to strengthen parity protections. For health plans operating across multiple states, the compliance picture is not uniform, and that makes evidence-based, consistently applied clinical review all the more critical. 

 Evidence-Based Reviews Across the SUD Continuum 

Accurate SUD level-of-care determination requires more than criteria matching. Clinical nuance is high: withdrawal severity, substance type, prior treatment history, co-occurring medical and psychiatric conditions, and social determinants of health all inform appropriate level of care (LOC) in ways that algorithmic review cannot reliably capture. Physician-led review, conducted by specialists with direct clinical experience in addiction medicine, is essential. 

MRIoA’s clinical review capabilities span the full SUD continuum, ranging from Level 1 (Outpatient) through Level 4 (Medically Managed Inpatient), including the clinical intensity within those levels. Appropriate level of care placement is not a one-time determination; the ASAM framework calls for ongoing reassessment as a patient’s clinical status evolves, with the goal of stepping down to the least intensive setting that safely supports recovery. 

The integrated treatment dimension matters here as well. MRIoA’s reviewer network includes addiction psychiatrists alongside internists, hepatologists, cardiologists, and other medical specialists. As SUD presentations increasingly intersect with complex medical conditions, the ability to bring multi-specialty clinical input to a single review becomes a meaningful differentiator. The growing clinical evidence base for medication-assisted treatment (MAT) also means that pharmacy-related reviews, MAT appropriateness, and concurrent medical management are becoming standard components of UM for SUD. 

MRIoA’s Capabilities for SUD and Detox Review 

MRIoA brings specialized depth to SUD clinical review that general UM programs cannot replicate: 

• Addiction psychiatry expertise at the intersection of SUD and medical management, drawing from a panel of 40+ behavioral health specialists who bring direct clinical experience to complex, comorbid presentations. 

• Defensible, criteria-grounded determinations using ASAM, InterQual, MCG, or client-specified criteria, applied by physicians with hands-on addiction medicine experience — not algorithmic matching. 

• Same-day review capability that meets the clinical urgency inherent in detox presentations, where level-of-care decisions must be made quickly and accurately. 

• State-matched reviewer licensing across all 50 states, which is particularly important for Medicaid SUD programs operating under state-specific utilization review requirements. 

 Matching Clinical Review to the Complexity of SUD 

As SUD treatment evolves toward integrated, chronic disease management, health plans and TPAs need a clinical review partner whose expertise matches the complexity of the cases they are seeing. Getting level of care right in SUD is not primarily a cost management exercise. It is a clinical quality imperative that directly affects members’ recovery outcomes, long-term total cost of care, and compliance with evolving regulations. 

MRIoA’s detox and SUD level of care review capabilities are purpose-built for this moment, grounded in 40+ years of clinical review experience and backed by physician specialists who bring real addiction medicine expertise to every case. 

Schedule a consultation to learn how MRIoA can help your organization ensure appropriate, evidence-based care decisions for every member.  

The post Getting Level of Care Right in SUD: Clinical Review Strategies for Withdrawal Management and Level of Care Placement appeared first on MRIoA.

Utilization management (including prior authorization) sits squarely at the center of this tension. When done well, UM ensures patients receive clinically appropriate, evidence-based care while protecting payers and patients from avoidable and unsustainable cost exposure. When done poorly, in opaque and inconsistent ways, it becomes a barrier to care that harms patients, frustrates physicians, and exposes organizations to regulatory and reputational risk.

The stakes are high and rising. Understanding how rigorous, independent UM actually works for specialty drugs is strategically and clinically imperative.

What Makes Specialty Drugs Different

High-cost specialty drugs are biologically complex therapies, including biologics, gene therapies, immunologics, and targeted oncology agents designed to treat serious, often rare or complex conditions. Costs can range from $5,000 per year for some biologics to well over $1 million for a single gene therapy treatment.

That price range reflects genuine clinical complexity. These therapies often target small patient populations, require specialized administration, and demand ongoing monitoring to assess response and safety. The clinical criteria governing their use are sophisticated, evolving rapidly, and highly specific to each subspecialty.

This is precisely why standard UM approaches fall short. A generalist reviewer applying broad clinical criteria to a gene therapy for a rare metabolic disorder is not equipped to make a sound determination. The science moves too fast, the populations too narrow, and the clinical nuance too deep for one-size-fits-all review. This complexity carries directly into how utilization management must be structured.

The Utilization Management Framework

Effective specialty drug UM operates across three stages, each serving a distinct clinical purpose.

Prior authorization establishes clinical necessity before treatment begins. For high-cost specialty drugs, this is a meaningful clinical checkpoint that protects patients from therapies that may not match their clinical profile and protects payers from expenditures with no corresponding benefit.

Concurrent review monitors ongoing treatment appropriateness. For specialty therapies, treatment trajectories can shift. A therapy that was clinically appropriate at initiation may need reassessment as patient response, disease progression, or emerging evidence changes the picture.

Retrospective review evaluates outcomes and cost-effectiveness following treatment. For value-based contracting and outcomes-linked agreements (a growing trend in specialty drug management), retrospective data is foundational.

Step therapy and evidence-based clinical criteria round out the framework, ensuring that treatment pathways reflect current clinical evidence rather than financial defaults.

What Good Utilization Management Actually Looks Like

Evidence-based, specialty-matched clinical criteria are the foundation for good utilization management. Every review should be grounded in current clinical evidence, not outdated criteria, financial targets, or administrative convenience. For specialty drugs, that means criteria developed and applied by reviewers with genuine subspecialty expertise in the condition and therapy being reviewed.

Specialty-matched physician reviewers are critical to a quality case review. When a health plan or PBM routes an oncology review to a generalist, or a rare disease case to a reviewer unfamiliar with the therapeutic landscape, the result is neither clinically sound nor defensible on appeal. Physician reviewers must be matched to the specialty of the case.

Turnaround times matter for both compliance and for patient outcomes. Meeting or exceeding CMS standards (72 hours for urgent reviews, seven days for standard) is not just a regulatory requirement. It is a clinical one. Delays in specialty drug authorization have direct consequences for patients managing serious conditions.

Transparent and written denial documentation is essential. Meaningful appeals require meaningful explanations. When payers cannot provide clear, evidence-based rationale for an adverse determination, they undermine the entire process and expose themselves to regulatory and legal risk.

Monitoring for disparate outcomes across patient populations should be a standard operational practice. Organizations serious about health equity cannot rely on external enforcement to identify disparities. They need internal visibility and analytical infrastructure to act on what they find.

The Case for Independent Review

Each of these best practices points toward the same conclusion: independent, physician-led review is the most defensible approach to specialty drug UM because it removes the financial conflicts that make in-house payer review vulnerable to criticism.

When a reviewer has no stake in the outcome of a coverage determination, the decision rests entirely on clinical evidence. That objectivity is not just ethically important. It is operationally valuable. Independent review produces decisions that hold up under appeal, withstand regulatory scrutiny, and can be documented and defended with transparency.

Organizations like MRIoA bring a combination of clinical depth, subspecialty breadth, and independence that in-house UM programs structurally cannot replicate. With more than 700 state-matched specialists spanning 150+ specialties, and a data infrastructure built on over 10 million clinical reviews, MRIoA provides the clinical rigor and analytical foundation that specialty drug UM demands.

Looking Ahead

The specialty drug pipeline shows no signs of slowing. Gene and cell therapies, value-based contracting models, AI-assisted UM tools, and continued CMS regulatory evolution will all reshape how payers manage high-cost therapies over the next several years. Each of these trends raises new questions about clinical criteria, outcomes measurement, and equitable access.

What will not change is the standard by which utilization management will be judged: does it ensure the right patient receives the right treatment at the right time or does it introduce barriers that serve financial interests at the expense of clinical ones?

Done right, UM is not the enemy of access to high-cost specialty drugs. It is one of its most important safeguards. The goal is getting it right every time, for every patient.

To learn more about how MRIoA supports health plans, PBMs, and TPAs in building clinically rigorous, defensible utilization management programs for specialty drugs, schedule a consultation with our team.

The post Safeguarding Care by Rethinking Utilization Management for High-Cost Specialty Drugs appeared first on MRIoA.

Keese brought an insider’s perspective on the noteworthy policies and political factors reshaping the business of healthcare, and what they mean for the members they serve.

The ACA Is Being Reshaped Through Regulation

The Trump administration is using regulatory tools rather than legislation to reshape how the Affordable Care Act (ACA) delivers health benefits. Two significant provisions in the U.S. Department of Health and Human Services (HHS) 2027 Notice of Benefit and Payment Parameters signal where policy is heading.

1. Expands Access to Catastrophic Coverage: Under the current framework, individuals over 30 cannot enroll in catastrophic plans without a hardship exemption. The proposed rule would extend eligibility up to 10 years for longer-term catastrophic coverage.
2. Non-Network Plans as Qualified Health Plans: Allows plans with narrow or no network requirements (also known as “skinny plans”) to be certified as Qualified Health Plans (QHP) on the exchange. This is a significant structural departure from the baseline ACA definition.

Keese’s assessment: the administration lacks the votes to pursue this legislatively, so it’s moving through every available regulatory channel instead. Healthcare organizations should treat the 2027 rule as a signal of structural change to come, not a technicality.

CMS Innovation Models and AI in Decision-Making

This administration has also doubled down on the use of Artificial Intelligence (AI) and technology to try to reduce fraud, waste, and abuse (FWA), while also pushing CMS innovation programs to be more efficient, cost-effective, and transparent. Several new models carry direct implications for payers and healthcare organizations:

• WISeR (Wasteful and Inappropriate Service Reduction): The first-ever prior authorization program in fee-for-service Medicare that leverages AI to expedite review for services vulnerable to FWA. Keese was skeptical WISeR survives a change in administration, but its existence sets a structural precedent.
• ACCESS (Advancing Chronic Care with Effective, Scalable Solutions): Tests new payment models using wearable devices and technology to improve chronic disease management. Applications were due in 30 states by April 2026 for a January 2027 start.
• MAHA ELEVATE (Make America Healthy Again – Enhancing Lifestyle and Evaluating Value-based Approaches Through Evidence): Tests 30 new chronic disease management models focused on MAHA principles.
• GLOBE (Global Benchmark for Efficient Drug Pricing): Applicable to Medicare Part B Drugs; triggers manufacturer rebates when a drug’s price exceeds an international benchmark.
• GUARD (Guarding U.S. Medicare Against Rising Drug Costs): The same international reference pricing model as GLOBE, applied to Medicare Part D drugs.

Regarding AI in coverage decisions, Keese was direct: using algorithms to drive claim review and coverage determinations is becoming politically untenable on both sides of the aisle.

Bipartisan legislation from Senators Warren (D-VA) and Marshall (R-KS) would require a human “learned intermediary” to review any AI-generated coverage denial before it’s issued. Organizations currently using AI in Utilization Management (UM) should treat this as near-certain regulatory direction, not a distant possibility.

PBM Reform: 155 Bills in 40 States

Signed into law on February 3, 2026, the Consolidated Appropriations Act contains what Keese described as “the most sweeping Pharmacy Benefit Manager (PBM) reforms ever enacted,” including:

• De-Linking: Prohibits PBM compensation from being tied to a drug manufacturer’s list price; requires a flat fee model in Medicare and commercial markets beginning January 1, 2028.
• 100% Pass-through of Rebates: Requires PBMs to remit to clients 100% of rebates, fees, alternative discounts, and other remuneration received from manufacturers, GPOs, etc., with quarterly reporting to clients.
• Eliminates Spread Pricing: Requires CMS to define and enforce “reasonable and relevant” Medicare Part D contract terms, including reimbursement and dispensing fees, and establish an appeals process.
• Enforcement of Penalties: Grants CMS authority to impose monetary penalties, and funds CMS up to $188 million for enforcement.
• Increased Transparency: Allows CMS to track payment trends to pharmacies and pharmacy inclusion in PBM networks, including a designation of essential retail pharmacies.
• Audits: Requires audits once per plan year. The Secretary of Labor will establish reasonable confidentiality restrictions for audited Rebate contracts.

At the state level, Keese identified at least 155 bills across 40 states addressing PBM practices. Two stood out: Arkansas House Bill 1150, which sought to bar PBMs or insurers from owning pharmacies, is currently blocked by a federal judge on Commerce Clause grounds. Meanwhile, Tennessee SB 2040/ HB 1959 is a nearly identical bill moving through the legislature committees.

The driving force behind these bills is bipartisan criticism of the vertical integration of payers, PBMs, pharmacies, and drug distribution. Keese flagged the pressure for structural separation as a trend to monitor heading into the 2026 campaign cycle.

What to Watch in the Next 12 Months

Based on Keese’s analysis, these policy developments require near-term operational attention:

• PBM Contracts: Rebate pass-through, spread pricing prohibition, and compensation delinking are now federal law. Contracts and formulary structures built on the prior model need to be reviewed now.
• 2027 Exchange Plan Design: Skinny plan and catastrophic coverage changes could reshape the competitive landscape. Payers, employers, brokers, and consultants should track the final rule closely.
• AI in UM: AI-driven claim review or prior authorization workflows should align with the learned-intermediary standard now ahead of likely regulatory action.
• Midterm Election Outcomes: The potential loss of Senate health committee leadership could create uncertainty around FDA policy, public health programs, and the timing of the next major healthcare legislation.
• State PBM legislation: With 155 bills in 40 states, multistate organizations face a rapidly fragmented compliance landscape. Arkansas and Tennessee are the immediate signals but more states will likely follow.

Watch the full March 2026 Washington Insider Webinar recording for Jay Keese’s complete analysis, including Q&A on vertical integration, Senate succession, and prescription drug cash-pay models.

The post Spring 2026 Washington Insider Recap: What Healthcare Leaders Need to Know appeared first on MRIoA.

The regulatory and political landscape is shifting fast. In this Washington Insider session, Jay Keese breaks down what the current administration’s agenda actually means for health plans, TPAs, and pharmacy benefit managers on the ground.

During this webinar we discussed:

• Midterm elections and the healthcare committee landscape
• Prior authorization under pressure
• PBM reform momentum
• Drug pricing and most-favored-nation status
• Vertical integration scrutiny

The post Spring 2026 Washington Insider Webinar appeared first on MRIoA.

That has changed.

Today, UM outsourcing is a strategic way to extend capacity in day-to-day operations while maintaining consistency, defensibility, and operational control as UM programs become more complex and regulatory expectations continue to rise.

The following are four best practices that prevent those breakdowns and help UM outsourcing deliver on quality, compliance, and performance expectations.

Why UM Outsourcing is Increasing

The growth of UM outsourcing isn’t just about staffing shortage (though those are real). Across the healthcare ecosystem, health plans, TPAs, PBMs, and other organizations are navigating the challenges of:

• Rising costs
• Scrutiny of prior authorization and utilization management policies
• Workforce shortages
• Administrative costs and burden
• Member satisfaction expectations

Each of these challenges creates a demand for an external partner that can deliver clinical depth, operational precision, and regulatory reliability.

Meanwhile, delivering more data on decisions by clinicians with same-state, specialty-match credentials requires a deeper level of clinical depth, process rigor, and documentation. These requirements are increasingly difficult for internal programs to staff and support.

Most organizations pursue outsourcing in one of three ways:

• Full outsourcing of end-to-end UM operations
• Co-sourcing for overflow, after-hours needs, or specific lines of business
• Specialty carve-outs for high-cost services or high-complexity areas that require deep clinical expertise such as behavioral health, post-acute care, advanced imaging, or specialty pharmacy

While the models differ, success relies on the same three underlying fundamentals to ensure outsourcing achieves the desired goal.

Best Practice 1: Define Scope and Success Factors Before Contracting

Effective UM outsourcing starts with clarity before the contract is signed. That means there’s a shared understanding of what is being outsourced and what defines success.

This begins with a precise definition of which activities to contract for, including:

• Functions such as intake, clinical review, peer-to-peer support, determinations, notices, appeals support, and reporting
• Coverage across lines of business, geographic regions, products, networks, and benefit plans
• Volume assumptions are based on current demand, projected growth, and seasonal patterns like Open Enrollment.

Success metrics should be agreed upon early and tied to both speed and quality. Common measures include:

• Turnaround time (TAT) by request type
• Clinical accuracy
• Denial rationale quality
• Appeal outcomes
• Indicators tied to provider or member experience

When scope and success are defined early, performance becomes measurable and addressable. It also creates a foundation for a genuine partnership where both parties win.

Best Practice 2: Evaluate Clinical Depth, Compliance Readiness, and Scalability

Clinical credibility is vital for success because capacity alone does not hold up when decisions are questioned by providers, regulators, or auditors.

Clinical Depth and Specialty Alignment

Many UM decisions require specialty-level expertise. Strong partners can demonstrate access to board-certified clinicians across numerous specialties with same-state licensure, familiarity with the populations being served (Medicaid, Medicare Advantage, commercial, or ASO), and in-house clinical leadership when cases are complex.

Accreditations and Delegated Authority

Accreditation is not a checkbox. It is a meaningful quality signal that separates high-performing IROs from basic review vendors. Not all outsourcing partners are NCQA or URAC accredited, and many cannot meet the standards required for delegated authority.

When a partner holds delegated authority, they can issue final determinations on behalf of the health plan. That means:

• The client can offload risk and administrative burden
• Final decisions carry the clinical and regulatory credibility of an accredited organization
• The partner becomes embedded in operations, not just an overflow vendor

When evaluating outsourced partners, confirm their accreditation status and whether they qualify for delegation across determinations, quality management, and compliance oversight. This distinction dramatically affects the value and risk profile of the relationship.

Compliance Posture and Audit Readiness

In today’s environment, your partner needs to operate like they’re audit-ready every day. Look for:

• Clear and deep understanding of current federal and state regulatory UM requirements
• Transparent audit support and documentation standards
• Formal quality management program that identifies trends and drives corrective action
• Expertise to consult with your team on important compliance risks and policy/process improvements
• Accreditations from organizations like NCQA and URAC that evaluate, certify, and improve service organizations

Technology and Integration Capabilities

Scalability isn’t just about staffing, it’s also about infrastructure. Your partner should have clear integration paths (workflows, data exchange, reporting), insightful reporting that you can use, and defined surge capacity for expected and unexpected spikes. The goal is stability under pressure.

Best Practice 3: Establish Governance that Keeps Performance Visible and Supports Continuous Improvement

Governance is what prevents outsourcing from turning into a black box. It should include regular performance reviews and clear operating rhythms, including regular check-ins that surface trends in volume, TAT, quality, and compliance risk early enough to act.

Clear ownership and escalation paths prevent issues from lingering. There should be escalation triggers for:

• Missed TAT
• Repeated documentation gaps
• High-risk or high-profile cases
• Provider friction or dissatisfaction
• Signs of guideline ambiguity or inconsistent application

The strongest partnerships treat QA as joint work. Find partners who schedule joint audits, regular calibration, and shared root-cause analysis to help distinguish between training gaps, workflow issues, and guideline ambiguity. When a partner is committed to making corrective actions tied to those findings, they demonstrate a focus on ongoing improvement. Additionally, look for an organization that has achieved NCQA and URAC accreditation.

Best Practice 4: Assess Operational Continuity and After-Hours Coverage Capabilities

One of the most overlooked dimensions of outsourcing evaluation is coverage continuity. Clinical volume doesn’t stop at 5 PM, nor do compliance requirements in some states. When a health plan misses turnaround time requirements over a weekend or holiday, the downstream consequences — member delays, provider friction, compliance exposure — are just as significant as a weekday failure.

When evaluating a UM outsourcing partner, assess their capacity for:

• After-hours, weekend, and holiday clinical review coverage
• Surge capacity during seasonal spikes due to open enrollment, plan design changes, etc.
• Staffing stability that doesn’t create backlogs when internal client teams are short

Member-friendly communication is equally important. Notices and determination letters that members can understand reduce unnecessary appeals, decrease call center volume, and directly support CAHPS and STAR rating performance. Evaluate whether your partner’s communication standards are built for clarity or simply legal defensibility.

Partners with strong operational continuity also tend to have the staffing infrastructure to absorb market uncertainty, like the enrollment volatility driven by Medicaid redeterminations or ACA market shifts, without passing that instability back to the plan.

Making Outsourcing Work

UM outsourcing delivers the most value when it operates as a clinical and operational partnership, not a short-term staffing solution. Choose partners who can combine:

• Clear scope and measurable success metrics
• Clinical depth, accreditations, and delegated authority
• Compliance readiness and scalable infrastructure
• Governance that enforces accountability and continuous improvement
• Operational continuity to include after-hours coverage and surge capacity

With a partner who demonstrates these capabilities, organizations can expand UM capacity without sacrificing quality, turnaround time, or provider and member experience.

To learn about our outsourced UM services, contact us to start the conversation.

The post 4 Best Practices to Get Better Outcomes and Better Member Experiences appeared first on MRIoA.