Healthcare organizations that want to increase value from utilization management—and improve provider relationships—need a risk-based, data-driven approach. By shifting from a disease-centric utilization management model to a network-centric one, healthcare organizations are realizing up to $20 million in total net financial savings and up to 80 percent reduction in the number of codes requiring review.
The need for this network-centric utilization management model is driven by the impact of the shift to the exchange model. By 2017, nearly one in five Americans will purchase benefits from a health insurance exchange, public or private. Payers are reporting significant losses in exchange markets, with several planning to pull out completely.
More healthcare organizations will likely face the same fate—disappearance from a growing market—if they do not evolve utilization management to align with a consumer market that has very different health characteristics.
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