Health plans third-party administrators (TPAs) are under pressure to lower medical costs while improving care outcomes. It’s not a new challenge, but the stakes are higher and the margin for error is smaller. Every clinical decision, from specialty drug authorizations to high-cost imaging, carries both financial and clinical implications.
Utilization management (UM) is one way to manage that balance. It evaluates whether care is medically necessary, appropriate, and delivered in the right setting. When done well, UM helps ensure the right care at the right time without unnecessary cost or delay.
The UM Challenge for Health Plans and TPAs
Operational Strain
Managing UM in-house demands extensive resources that many health plans and TPAs are challenged to maintain. It requires a robust in-house staff and an extensive panel of physicians and pharmacists with diverse clinical specialties, same-state licensure, and the expertise to correctly interpret complex medical guidelines. As review volumes increase — particularly for specialty drugs and advanced imaging — the nationwide clinical workforce shortage makes it increasingly difficult to staff appropriately.
Regional plans and TPAs with lean resources face an even greater challenge, unable to support the full range of physician specialties needed for timely, appropriate clinical review across all disease states or categories.
Regulatory Complexity
UM regulations are not static. They shift often (sometimes quarterly) at both the state and federal levels, encompassing mandatory turnaround times (TATs), detailed appeals processes, and extensive reporting requirements. Staying current requires ongoing monitoring, policy updates, and staff training across all these dimensions.
Missing a deadline or misapplying a rule carries serious consequences: financial penalties, compliance findings, increased legal exposure, reputational damage, and even loss of accreditation or certification. For plans operating across multiple states, this regulatory complexity multiplies exponentially, creating significant compliance risk.
Technology Gaps
Manual workflows like faxed requests or emailed spreadsheets are still common. They slow down reviews, increase errors, and make it harder to scale. Additionally, limited interoperability between legacy systems creates information silos that fragment the review process and impede decision-making.
Without interoperability, there’s limited visibility into review status, turnaround time, or trends. That makes it hard to evaluate performance or identify where delays are happening. Furthermore, effectively leveraging AI capabilities remains challenging due to evolving regulatory constraints, particularly around clinical decision support and protected health information.
Provider & Member Friction
When UM takes too long or isn’t clear, the result is frustration. Providers are left waiting. Members don’t understand why care is delayed or denied.
These negative experiences steadily erode trust in the health plan and damage long-term relationships with both members and providers. Over time, they lead to increased appeals, formal complaints, and significant provider abrasion. When providers and members consistently encounter friction in the UM process, the resulting administrative burden can quickly offset any cost savings the program was designed to achieve.
Why Outsourcing Makes Strategic Sense
As health plans evaluate their UM strategy, many are finding that the build-versus-buy decision increasingly favors external partnerships.
Strategic outsourcing delivers immediate value while avoiding the significant capital investment required to build comparable capabilities in-house. Outsourcing UM to a partner addresses many of these challenges through:
- Scalable clinical resources to handle volume fluctuations
- Clinical and regulatory expertise to mitigate compliance risks, reduce provider abrasion and improve efficiency
- Smart technology integration that creates a foundation for automation, time-saving integration
- Comprehensive reporting and analytics for actionable insights into cost drivers and clinical outcomes
That’s where outsourcing UM to MRIoA, the industry’s most comprehensive clinical review partner, becomes a strategic advantage that delivers immediate ROI while eliminating the operational challenges of in-house management.
The MRIoA Advantage: ClearPath UM™
MRIoA’s ClearPath UM™ solution is a fully outsourced, end-to-end clinical utilization management service that integrates seamlessly with a payer’s clinical operations and member care delivery team. It leverages a combination of technology and clinical expertise to deliver faster decisions, reduce administrative burden, and ensure regulatory compliance.
Benefit 1. Lower Administrative and Medical Costs
- Reduced Prior Authorizations: By streamlining the PA list to eliminate low-value reviews, ClearPath UM helps plans focus on high-impact cost drivers. This reduces unnecessary overhead and medical expenses.
- Lower Admin Costs: By outsourcing to MRIoA, plans reduce the internal resources needed for case reviews, resulting in significant administrative savings.
Benefit 2. Operational Efficiency
- Faster Turnaround Times (TAT): ClearPath UM has improved TAT compliance from 17% to 95%, addressing backlogs and reducing costly auto-approvals.
- Technology-Enabled Automation: With API and RPA integration, prior authorizations flow seamlessly between the client’s system and the ClearPath UM platform, reducing manual handoffs while speeding implementation.
- High Accuracy Reviews: MRIoA employs clinician-led reviews supported by smart technology, resulting in more consistent, guideline-adherent determinations.
Benefit 3. Improved Clinical Outcomes
- Avoidance of Unnecessary Procedures: MRIoA’s clinical expertise ensures that only medically necessary treatments are approved, reducing patient risk and improving outcomes.
- Enhanced Member Experience: Integrated second-opinion services and health education help members make informed decisions about their care, further enhancing outcomes.
Benefit 4. Regulatory Confidence
- Compliance Assurance: MRIoA holds dual URAC accreditation, NCQA accreditation, and maintains licensure in all 50 states, ensuring decisions meet all federal and state requirements.
- Data Security: With HITRUST certification and AICPA/SOC compliance, MRIoA guarantees secure and confidential handling of sensitive clinical data.
ClearPath UM™ in Action: Transformative Results
A regional Blues Plan engaged MRIoA to solve critical compliance and turnaround time challenges stemming from overwhelming prior authorization volume, clinical staffing shortages, and inefficient UM workflows. This created a cascade of problems: excessive auto-approvals driving unnecessary medical spending, compliance violations threatening URAC accreditation, and ultimately putting the plan at significant risk for lost contracts and revenue.
Working directly within the plan’s system to handle 700+ cases daily, ClearPath UM strategically optimized prior authorization by deploying appropriately licensed clinical specialists to address complex multi-state and multi-line of business requirements. This integrated approach delivered remarkable results:
- TAT compliance improved from 17% to 95%,
- Administrative approvals decreased from 32% to 7%,
Most significantly, MRIoA’s intervention lowered the combined Medical Claims Spend and Administrative costs by $32M annually, delivering an impressive ROI of 2.4:1.
The Bottom Line: Strategic UM Delivers Measurable Value
Lowering costs and improving clinical outcomes with end-to-end utilization management is possible — and sustainable. But it requires the right infrastructure, clinical expertise, and technology.
Outsourcing to MRIoA brings all three. It gives health plans a scalable, compliant, and data-driven way to manage utilization — while improving care and reducing administrative strain.
