Industry Report
Should We Outsource Our Utilization Management?
Many health-plan leaders ask themselves whether they should continue performing utilization management (UM) reviews in-house or outsource. Staffing shortages, escalating administrative costs, and a changing regulatory landscape make the work harder (and riskier) every year. By partnering with a high quality UM review vendor, payers are becoming better equipped to manage the complexity of expanding capacity and redirect internal talent toward higher value initiatives.
Is this the right move for your organization?
Table of Contents
Why Outsource UM?
Outsourcing UM reviews to a high quality specialized UM partner allows health plans to offload day-to-day administrative lift while gaining elastic capacity and deeper clinical expertise.
A few reasons UM outsourcing makes sense:
- Speed & Quality: Shorten turnaround times and avoid unnecessary approvals.
- Capacity: Rapidly scale review volume without adding headcount.
- Expertise: Tap board-certified subspecialists who meet NCQA / CMS credentialing requirements.
- Cost: Convert fixed administrative overhead into a predictable, per-case expense.
- Compliance: Stay continuously aligned with evolving federal and state regulations.
- Benefit: Free internal clinicians to focus more on valuable member care and provider engagement.
BHM has a long-standing reputation in the industry as a quality leader as a UM partner. We have a deep understanding of the challenges clients face and the benefits they reap from working with us to support them. While every client presents with their own set of unique needs, there are some commonalities we’ve seen over the years that may resonate with you. Let’s explore them:
Scalability and Operational Efficiency
Payers benefit from outsourcing when day-to-day operations hit three pressure points:
- Auto Approvals: Auto adjudication in expensive and complex cases; Credible delegated support minimizes exposure.
- Volume spikes: Unexpected gaps in resources and market fluctuations happen; Outsourced teams support capacity on demand.
- Specialty gaps: Board-certified subspecialists (behavioral health, transplant, oncology) are scarce and costly to recruit; vendors supply credentialed experts instantly.
ROI Snapshot: Health plans that outsource report lower per-case review costs and faster turnaround times.
Compliance and Risk Management
Outsourcing mitigates challenges arising from regulators and accrediting bodies raise the bar every year:
- Evolving regulations: CMS, state DOIs, and NCQA continually update UM rules; noncompliance risks fines, corrective-action plans, and lost STAR bonuses.
- Accreditation audits: Maintaining NCQA UM accreditation demands airtight documentation; vendors embed compliant workflows and audit trails.
- Technology deficits: Automated decision-support platforms and real-time audit dashboards can take years to build, leading vendors to provide them out of the box.
Bottom Line: Outsourcing de-risks UM operations and keeps you inspection-ready every day.
Provider and Member Experience
Frictionless authorizations translate directly to satisfaction and retention:
- Provider friction: Lengthy reviews create grievances and threaten network stability; outsourced teams slash decision times.
- Member delays: Faster, evidence-based approvals prevent care postponements that drag down CAHPS and STAR scores.
- Strategic refocus: Offloading reviews frees internal clinicians for higher-value care-management and quality-improvement initiatives.
Outcome: Stronger provider relations, higher member satisfaction, and improved clinical results.
More on Utilization Management:
Scalability and Operational Efficiency in Outsourced Utilization Management
BHM Earns NCQA Re-Accreditation for Utilization Management
5 Reasons Providers Should Use Utilization Management Software
Behavioral Health Utilization Review: Improving Patient Outcomes
Is Your Organization Ready?
We prepared a step-by-step playbook for choosing the right utilization-management partner. Inside, you’ll find the precise questions and benchmarks that matter (spanning from compliance to scalability to overall experience), so you can evaluate any UM vendor with confidence.
Download the guide now to compare vendors side-by-side and lock in a partner who protects compliance, controls costs, and keeps your members and providers satisfied.
What's Inside the Guide?
● Handy checklist: One quick page of must-ask questions (accreditation, surge capacity, clinical skills, tech, cost) lets executives size up UM vendors in minutes.
● Compliance + surge tips: Spells out exactly what to ask about URAC, NCQA/CMS rules, and how a partner keeps reviews on time during sudden volume spikes.
Frequently Asked Questions (FAQs)
Does outsourcing UM reviews jeopardize our NCQA or URAC accreditation?
A reputable vendor follows the same credentialing, physician-review, and timeliness requirements you do; often exceeding audit benchmarks.
How quickly can we scale capacity during peak seasons with a utilization management vendor?
Most vendors can double or triple daily review volume within two weeks by activating a pre-credentialed reviewer pool.
Will outsourcing utilization management reviews increase denial rates and appeals?
On average, vendor review programs reduce denial overturns by applying consistent, evidence-based criteria and second-level physician review before issuance.
How do we ensure Protected Health Information stays secure when outsourcing utilization management reviews?
Look for HITRUST-certified vendors that offer HIPAA-compliant platforms, role-based access controls, and end-to-end encryption.
What specialties can an outsourced reviewer panel cover?
Top vendors staff board-certified physicians and nurses across adult, pediatric, behavioral health, oncology, transplant, cardiology, orthopedics, and more.
Why Choose BHM?
We proudly stand behind our reputation in the industry as experts in utilization management.
Our proven process has served our clients well for over 20 years and our unwavering focus on serving clients with excellence has set us apart.
Here are a few ways we demonstrate that commitment.
Trust
Reliable Partner
We’ve built our reputation on integrity, transparency, and delivering dependable services that organizations trust to support critical decisions in cost effective care.
Expertise
Industry Knowledge
Our team of seasoned professionals and clinical experts provide unparalleled insights and guidance tailored to meet the complex needs of healthcare payers and providers.
Innovation
Driving Progress
We combine advanced technologies and forward-thinking strategies to deliver efficient, scalable solutions that enhance outcomes and streamline processes.
Outcomes
Measurable Impact
Our systems are designed to employ data-driven insights to help organizations improve quality, reduce costs, and meet compliance standards for lasting success.
Partner with BHM Healthcare Solutions
With over 20 years in the industry, BHM Healthcare Solutions is committed to providing consulting and review services that help streamline clinical, financial, and operational processes to improve care delivery and organizational performance.
We bring the expertise, strategy, and capacity that healthcare organizations need to navigate today’s challenges – so they can focus on helping others.
Are you ready to make the shift to a more effective process?
