Sagility, LLC, a technology-enabled healthcare business process management (BPM) company, has announced the launch of its Utilization Management as a Service (UMaaS) offering to assist health plans seeking to improve prior authorization for their provider partners and increase compliance with the Centers for Medicare & Medicaid Services (CMS) regulations.
Utilization management (UM) and prior authorization, which is the most commonly practiced form of utilization management, are both highly regulated, and health plans can face high penalties and fines when they are out of compliance. The existing U.S. nursing shortage is one factor exacerbating the pain for payers who struggle to render decisions in a timely manner. In late 2022, CMS proposed a mandate that requires payers to turn around cases faster, as well as provide real-time decisions. The proposed rule will increase pressure on payers to improve their UM operations. If finalized, the rule will become effective in January 2026.
Sagility’s UMaaS accelerates the prior authorization process by leveraging technology to render real-time determinations and shorten the clinical review time by more than 50% with precision using generative AI and machine learning technology, according to internal studies. With a combination of skilled clinical staff, collaborative peer educative process, and tech enablement, Sagility’s UMaaS accelerates average turnaround time to, typically, less than two days.
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“Sagility’s UMaaS addresses the complexity of utilization management amidst an ever-changing regulatory environment, with regards to improving provider satisfaction and enhancing timely care to the members,” said Krithika Srivats, Senior Vice President of Clinical Practice and Products at Sagility. “We work closely with payers to help improve their utilization management operations via a service that delivers real-time decisions and faster turnaround time, ensuring timely and high-quality care to the members, compliance to CMS and state regulatory bodies and while improving provider satisfaction.”
The UMaaS model offers a true end-to-end solution for payers looking for UM specialty and clinical operations that may be struggling to staff nurses, provide optimization of operational cost, and meet CMS regulatory requirements, using Sagility’s next-gen technology. UMaaS is Utilization Review Accreditation Commission (URAC) accredited and allows payers who are looking to stand up a UM program, a simple yet highly effective option to become a well-managed plan while improving member outcomes. With UMaaS, payers benefit from overall reduced cost of operations thereby reducing price per authorization by more than 30%, improved provider Net Promoter Score (NPS), and low member and provider appeals.
In addition, payers can leverage Sagility’s comprehensive UM 360-degree approach for greater impact. Sagility’s specialty solutions support payers’ need to address the rising cost of specialty healthcare procedures such as sleep testing, endoscopy, or surgery, where Sagility’s comprehensive approach impacts both quality and cost through an educative, peer-review model, which results in reduced specialty service medical spend on the Medical Loss Ratio (MLR) up to 15% or more, enabling payers to mitigate the pressure of rising healthcare cost.
Sagility serves Commercial, Medicare Advantage, Medicaid, children’s health plans, and qualified health plans in all 50 states.
SOURCE: BusinessWire