Optimizing Utilization Management with Technology

The technological capabilities have changed the shift from volume to value-based care. The combination of value-based delivery with actionable intelligence and new care delivery models, and value-based payment with new reimbursement models with selected provider networks have pushed providers and payers to operate across a transparent, administratively simple, shared ecosystem.

Nalashaa can help in mitigating the current utilization management challenges through the solutions mentioned below.

  • Improve Intake Management and Member Management by automating and integrating with EHR and enabling the system to accept CCDAs
  • Real-time patient updates from existing medical information systems like EHR, Lab data, Pharmacy, Patient Portal and other physician practice management systems etc
  • Send Automatic notifications to patients on updates of their medical information
  • Auto triggering and sending educational materials to patients and making it accessible over patient portals
  • Enabling member specific custom reports and dashboards for deeper insights into their health
  • Improve episode management by multi-faceted ability to receive UM requests via web-based entry on a provider portal, call center and/or fax submission and tracking.
  • Enabling the criteria and rules to validate authorizations to avoid duplicate requests
  • Implementing and enabling auto approval rules and criteria based on the client’s workflow
  • Managing the correspondence and auto-integration with the document management system
  • Managing episode specific assessments and making structures in order to make the information useful
  • Providing episode specific reports and automating authorization export to the claims system. Dashboards could aid in visualizing the same data
  • Improve authorization review process by
  • Implementing auto approvals through the application of standard or custom criteria. This will align organizations with value-based care, where provider-payer communication is expected to be in real-time to guide timely decisions
  • Implementing reliable and well-informed third-party reviews
    • On clients’ request, the system can securely be integrated with one of the following third-party applications to provide care guidelines:

* Care WebQI Guidelines (CWQI) * InterQual

  • Implement Palliative care Management
  • Some of the palliative care measures which can be implemented are
    • Telehealth technology to connect patients with palliative consultation teams, eliminating the inconvenience of traveling to hospitals or emergency departments for care
    • Incorporating palliative care assessments helping case managers to assess the patient for palliative care management
    • Implementing automated discharge planning
  • Enabling discharge assessment and triggering case management referral based on the assessment outcome
  • This will reduce the chances of readmission and increase patient satisfaction
    • Improving provider management by
  • Implementing provider portals enabling authorization creation, authorization submission, provider attachment, informative dashboards etc.
  • In/ Out network provider management by implementing in/out of network algorithms per client requirement
  • Enabling the out of area provider access to the provider portal as per client requirement
  • Alerts management by alerting the provider with industry standard and custom alerts


As healthcare in the US is moving towards value-based care, Utilization Management is evolving as must concept to efficiently manage the resources which in-turn improves the ROI while providing quality service. Even though it began as a way for health care organizations and professionals to evaluate the efficiency and effectiveness of the services provided to the patients, it has emerged into a proactive planning and decision-making solution. Availing the progressions in technology, utilization management has the potential to revolutionize the services of providers, payers by providing cost-effective quality care, if implemented intelligently.

The following two tabs change content below.
Shridhar Purohit

Shridhar Purohit

Shridhar Purohit is a Healthcare IT consultant with extensive experience in developing product strategy, consulting and implementation of health care business solutions.
Shridhar Purohit

Latest posts by Shridhar Purohit (see all)

Leave a Reply

Your email address will not be published. Required fields are marked *