Optimizing Utilization Management in Professional Case Management Practice

BY MICHAEL B. GARRETT, MS, CCM, CVE, CPCHE

Utilization management, also called utilization review, has been present in the U.S. healthcare system for several decades. Initially, utilization management programs were focused on addressing overutilization, meaning excessive use of healthcare services that lead to waste in the system without realizing significant improvements in healthcare quality. When utilization management programs were launched, most of healthcare was reimbursed based on a fee-for-service model which, in some instances, incentivized overutilization. As reimbursement models have evolved, utilization management has also shifted from a sole focus on overutilization to also include a focus on quality and compliance with commended national standards. The goals of utilization management include:

• Ensuring adherence to evidence-based clinical guidelines
• Promoting patient safety and quality
• Controlling the costs for unnecessary medical services

Although these are lofty goals, they have not always or consistently been met. There are concerns about delays in care and barriers to critical healthcare services. There are a number of concerns about the negative, and potentially unintended, consequences of utilization management, including:

• Excessive administrative burdens on providers
• Unnecessary delays in appropriate and necessary healthcare services for patients/clients
• Lack of transparency in the review process
• Detrimental impact on physicians, including burnout and loss of autonomy
• Negative impact on patients, including long wait times for decisions and confusion about options if services are denied

The professional case manager may be involved with utilization management, or may be adjacent to utilization management programs. In the most recent national job-tasks analysis of case managers from various professional disciplines and practice settings, the domain of reimbursement includes a sub-task that includes “apply utilization review/management principles, guidelines, and tools.” At a minimum, there should be an awareness of utilization management procedures as well as solid communication between case management and utilization management teams for timely and efficient review processes.

The “Consensus Statement on Improving the Prior Authorization Process” identifies five areas that offer opportunities for improvement in prior authorization programs, including:

1. Select application of prior authorization
2. Prior authorization program review and volume adjustments
3. Transparency and communication regarding prior authorization
4. Continuity of patient care
5. Automation to improve transparency and efficiency

This Consensus Statement was endorsed by a range of organizations in several sectors in healthcare including the American Hospital Association, America’s Health Insurance Plans, American Medical Association, American Pharmacy Association, BlueCross BlueShield Association, and the Medical Group Management Association. Case managers work in a variety of work settings, and these organizations appear to represent the majority of work settings of case managers. Case management leaders, in particular, can advocate within their organization to develop and implement utilization management processes and procedures that adhere to these opportunities for improvement.

More recently, the Center for Health Care Strategies has issued an Issue Brief entitled “Striking a balance in utilization management: State strategies for Medicaid managed care accountability.” Although this is aimed specifically at Medicaid Managed Care Organizations (MCOs), these strategies could be applied to other health programs. These select strategies are recommended to strengthen oversight and accountability for MCO-led utilization management functions, including:

1. Reduce select MCO prior authorization requirements to decrease burden and improve access to care
2. Work with MCOs to centralize and standardize prior authorization requirements
3. Use patient and provider feedback to identify potential problems
4. Ensure patients and providers understand adverse determinations and potential next steps
5. Develop contract requirements that promote access to specific services
6. Consider public reporting to improve transparency and outcomes
7. Train and support state staff overseeing utilization management

This Issue Brief also identifies some key points regarding the use of artificial intelligence (AI) in utilization management, including:

• AI has the potential for streamlining the utilization management processes for expedited decision-making while lowering the costs and saving time for MCOs and providers
• AI tools, however, could also make decisions in a “black box” with little insights for providers, state officials, and accrediting organizations in overseeing utilization management decisions
• AI tools should not be the sole decision-makers for denying or limiting care
• There needs to be transparency about how AI is being used and how it makes decisions
• There continues to be the need for oversight by state officials and accrediting agencies of AI tools
• There needs to be verifiable assurances that AI developers avoid “algorithmic discrimination” by conducting tests to measure the fairness and equity in the use of AI tools

The Issue Brief indicates that there can be benefits from the use of AI tools in utilization management process while there need to be strategies to mitigate the risks and unintended consequences of these tools.

The professional case manager can support improvements in the utilization management processes in a variety of ways, including:

• Learn the utilization management and appeals processes. This means the case manager needs to understand what services and procedures require prior authorization or some form of review, and, when necessary, let the client and/or family know about these requirements. The case manager can also become familiar with the appeals process when denials occur, so that the client and/or family can be informed of the option for appealing those denials.
• Identify what the client understands and expects from the medical services. The case manager can discuss with the client what they know about the services, including how to prepare, what the service involves, and what the expected outcomes are. As a result, the case manager can identify and then address any gaps in knowledge. In addition, the case manager can promote appropriate preparation for the services, and coordinate follow-up care after the services are performed.
• Describe alternative, potentially more conservative, treatment options if the services are denied. If the requested services are denied and the appeal process is either not pursued or is unsuccessful, the case manager can describe what alternative treatments are available. For example, if the client is denied a back surgery due to lack of a trial of physical therapy, the case manager can refer the client to their provider to get a referral for physical therapy. In this case, the case manager can also describe the process of physical therapy, including goals and the involvement of the client in the therapy process.
• Provide advocacy and support when the client chooses to file an appeal. If the medical service is denied and the client wants to appeal, the case manager can provide support, navigation, and advocacy through the appeals process. It is the client’s decision to pursue an appeal, regardless of what the case manager believes the likelihood is for overturning the denial decision.
• Coordination with the utilization management team for early referrals of potential case management candidates. The case manager and the broader case management team can collaborate with the utilization management team, to ensure the timely and appropriate referrals of potential case management candidates. The teams need to develop referral criteria based on the experiences the case management team has with potential candidates. These criteria may change and evolve over time, so the criteria should be revisited periodically. The teams also need to set up a communication mechanism about how, where, and when referrals can be made.

Utilization management is likely going to remain in our healthcare system for the foreseeable future. Although the case management may not conduct the review process in utilization management, there needs to be an awareness of the procedures and potential impacts on the clients served through the case management program. These strategies, techniques, and methods can provide guidance to case managers to participate in the continuous improvement in utilization management in order to improve the access to, experience of, and outcomes from healthcare services.

REFERENCES

American Hospital Association et al. n.d. Consensus statement on improving prior authorization process. N.d.

Case Management Society of America. CMSA Standards of Practice for Case Management. 2022. www.cmsa.org

Giardino A.P. & Wadhwa R. Utilization Management. [Updated 2023 Jul 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan.

Smithey, A. and Melo, N. 2026. Striking a balance in utilization management: State strategies for Medicaid managed care accountability. Center for Health Care Strategies, Brief, 2026.

Struthers, A.; et al. 2024. Utilization management and physician burnout. The American Journal of Managed Care. Vol. 30, no. 11, November 2024, pp. 561-566.

Tahan, H. et al. 2025. The continued evolution of the professional case manager role: A national study from the Commission for Case Manager Certification. Professional Case Management. Vol. 30, No. 4, pp. 127-145.

Author Name, Credentials, and Job Title:

Michael B. Garrett, MS, CCM, CVE, CPCHE

Independent Clinical and Health Equity Consultant

Michael B. Garrett, MS, CCM, CVE, CPCHE, has more than 40 years of experience in utilization, case, and population health management. This has included working with public and private sector benefit plans. Recently, he has focused on improving health equity for historically underserved communities. He has authored articles, books, and blogs on a range of case management and health equity topics. He currently serves on the editorial board of the peer-reviewed journal Professional Case Management, the URAC health equity council, and the CMSA DEIB committee. He holds a Bachelor of Arts in psychology, and a Master of Science in clinical psychology. He is a Certified Case Manager®, Certified Vocational Evaluation Specialist, and a Certified Professional in Clinical Health Equity™.