Fixing Prior Authorization: How to Improve Outcomes Using Episodic Care Paths

As the industry becomes oriented toward value-based care and its focus on high-value outcomes, utilization management must evolve to address the entire patient care journey, often across multiple episodes of care. The widespread adoption of utilization management (UM) programs has proven effective both for advancing patient safety and controlling unnecessary medical expense. However, traditional UM remains locked into the legacy practice of managing individual services versus taking an episodic view centered on long-term patient outcomes. As the industry becomes oriented toward value-based care and its focus on high-value outcomes, UM must evolve to address the entire patient care journey, often across multiple episodes of care.

With traditional UM, health plans apply their one-size-fits-all review criteria which are rarely transparent to the provider to make case-by-case decisions as to whether a requested service is medically necessary and clinically appropriate. When a physician submits a prior authorization request, the health plan can take up to two weeks to review the case; if additional information is needed, this timeline could be extended. In the meantime, the patient is left waiting to receive care they most likely need. The fact that UM so often functions as a delaying tactic is one of the main reasons physicians maintain a deep distrust of the prior authorization process.