Initial Challenge

A leading health plan faced significant challenges in recruiting, training, and retaining full-time medical directors experienced in utilization management (UM) for prior authorization (PA) and concurrent reviews. The difficulty in finding and retaining qualified physicians for these roles can make it challenging to maintain a stable and effective review process. The cost of recruiting and onboarding a new medical director, which can reach up to $60,000, further compounded the issue. The health plan needed a more efficient and cost-effective solution to manage their PA and concurrent case reviews, particularly as they aimed to expand the scope of their UM program to include a new prior authorization policy.

UMS Solution

The health plan partnered with ExamWorks UM Strategies (UMS) to recruit and manage full-time physicians for prior authorization and concurrent case reviews. Initially requesting one full-time physician, the partnership quickly expanded to four full-time physicians with plans to include a fifth dedicated physician for specific specialty-matched prior authorizations. UMS's well-developed network of experienced UM physicians and robust training protocol enabled rapid onboarding and immediate productivity, addressing the health plan’s staffing and regulatory challenges in real-time.

Performance Metrics

UMS consistently met or exceeded the health plan’s performance metrics, ensuring a 100% compliance with turnaround time standards. The quality of clinical reviews was consistently high. Late cases, which can have serious regulatory implications, were never an issue, helping the health plan maintain compliance.

Key Takeaways

  • Cost Efficiency: Outsourcing to UMS significantly reduced the costs associated with recruiting, onboarding, and training in-house medical directors.
  • Rapid Onboarding: UMS physicians were fully productive within a few weeks, compared to the months typically required for in-house training.
  • Regulatory Compliance: UMS's consistent performance in meeting turnaround times ensured the health plan remained compliant with regulatory requirements.
  • Focus on Higher-Value Initiatives: By outsourcing PA case reviews, the health plan’s in-house medical directors could focus on more strategic and high-value initiatives.

This partnership demonstrates the value of leveraging specialized expertise to enhance operational efficiency and regulatory compliance in the healthcare industry. Contact us today at UMSInfo@ExamWorksUMS.com or call 833.861.EUMS to learn how ExamWorks UM Strategies can support your organization’s success.