As health plans implement value-based payment models, reducing overutilization is crucial to improving outcomes and minimizing costs. However, balancing utilization and quality remains challenging. 

Leading utilization management solutions provider Agadia integrates clinical expertise and advanced analytics to help health plans implement strategies balancing utilization and quality outcomes.

Here are 5 strategies payers are employing:

1. Enhance Precertification Criteria

While pre-authorization is necessary to verify medical necessity, blanket requirements can create barriers. Experts suggest targeted precertification based on evidence-based guidelines and claims analysis. For example, tightening controls on elective procedures with high variation between providers. Automating reviews allows efficient decision-making without denials for true medical needs.

2. Strengthen Concurrent Review

Many plans still rely on retrospective review after treatment. But intervening during care presents opportunities to proactively redirect plans. Concurrent review tools apply the latest treatment pathways and risk rules to identify overutilization in real-time. This supports authorization of the right site of care or discontinuation of unproven therapies.

3. Conduct Provider Profiling

Analyzing individual physician and facility patterns identifies significant outliers. Proprietary models risk-stratify providers based on quality metrics and cost ratios versus peers. This aims to optimize utilization where truly unnecessary, not constrain access.

4. Promote Evidence-Based Care

Coordinating standardized, condition-specific treatment protocols incorporating research improves consistency and efficiency. Plans offer rewards for providers meeting pathway metrics for costs and outcomes. Pre-approval ensures adherence to guidelines for higher risk areas.

5. Invest in Complex Case Management

For high-need members, dedicated case and disease management coordinates intensive, long-term care versus one-off reviews. Specialized teams collaborate with patients, providers and community services to address issues driving costs. Personalized coordination aims for the right care setting.

Summary

In summary, applying thoughtful multi-pronged strategies fosters overutilization reduction without compromising quality or access. Utilization management expertise and predictive analytics can help health plans succeed under value-based care.