Authorization processes are often where care slows down. Not because clinical teams aren't ready, but because the workflows behind them aren’t. Manual steps, inconsistent communication, and unclear payer expectations lead to stalled cases, staff frustration, and, more critically, delays in treatment.

The scope of this challenge is significant. According to 2024 data from Premier Inc., nearly 15% of medical claims submitted to private payers are initially denied, with Medicare Advantage denial rates reaching 15.7%. The Kaiser Family Foundation reports that HealthCare.gov insurers denied nearly one out of every five claims (19%) for in-network services in 2023.

These aren’t isolated issues. They compound. Every time an authorization request is missing data, sent late, or lacks clarity, it adds another layer of inefficiency to the care cycle. 

Which is why rethinking utilization management matters. 

When done right, it doesn’t just help providers meet payer requirements — it moves patients forward. It supports clinical decisions, reduces delays, and builds a system where approvals feel predictable, not burdensome.

Let’s look at how organizations are approaching the utilization management process differently, across seven essential steps.

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Optimizing Utilization Management in Healthcare: 7 Essential Steps 

Let’s go over the steps involved in improving the utilization management process:

1. Referral Intake That Doesn’t Slow Teams Down

The way referrals enter your system matters. Often, they come in through multiple channels, and just as often, they’re missing details that require follow-up.

Instead of chasing those gaps, structured intake processes categorize referrals as they arrive. With automation and smart routing, requests can be flagged based on urgency or complexity. Teams then focus on where they’re needed most. This approach reduces errors, saves time, and provides better visibility from the very first touchpoint.

Technology Integration: EDI tools, automated submission platforms, and real-time dashboards all help reduce lag. When those tools connect to EHRs and billing systems, fewer steps are missed.

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2. Eligibility Checks Before Coverage Problems Surface

Denials due to eligibility should be rare. But they’re not, mostly because benefit verification happens late or inconsistently.

The fix is simple, even if it’s not always easy to implement: verify coverage, authorizations, deductibles, and service-level exclusions upfront, not midway through scheduling, and not post-visit. 

This early check makes everything else more efficient. It prevents misunderstandings, reduces rework, and gives both providers and patients a clearer understanding of what to expect.

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3. Documenting Medical Necessity and Making It Count

Payers need documentation that justifies care. That’s a given. But if the language used doesn’t match the clinical policy or lacks key details, it won’t get approved, even when the care is appropriate.

This is where internal alignment matters. Evidence-based documentation aligned with CMS guidelines and payer-specific criteria ensures 95 %+ approval rates while maintaining regulatory compliance. 

Every policy update or payer rule change can shift what's needed. Training teams to spot those shifts and document accordingly improves approvals and reduces delays.
Whether it's CMS audits or internal risk assessments, compliant workflows protect the organization. Proactive monitoring helps identify issues before they become liabilities.

So, do pre-submission reviews. The point isn't to add work; it's to ensure that the work already being done supports the request effectively. And when a denial happens, a strong paper trail ensures there's something worth appealing.

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4. Submitting Authorizations That Don’t Get Lost in the System

Submitting an authorization should be trackable, but in many workflows, it’s still not. Without a clear system for submission, status checks, and follow-ups, cases can sit in queues with no movement. Standardized digital submissions (especially through EDI) solve part of the problem. 

AI-powered dashboards with real-time tracking capabilities achieve a 24-48 hr processing turnaround while eliminating manual intervention errors. You can act when you can see where a request is and what’s holding it up. 

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5. Communicating with Payers, Not Just Sending Requests

Getting approval isn’t always about the initial request. It’s about how the conversation continues after that. That’s why payer communication should be structured. Not just emails or calls, but specific timelines, designated escalation paths, and templates that clarify what’s being asked and why. And when denials come in, the appeals process should be just as clear.

Standardized templates, shared case notes, and escalation guidelines support consistency, especially when teams are under pressure.

Payers, like providers, benefit from consistency. The more reliable your communication, the more efficient the resolution becomes.

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6. Turning Approvals Into Action

Getting the green light is just one part of the story. What happens next is how quickly the care is scheduled, whether all the approved parameters are followed is just as important.

Authorizations often include date limits, procedure codes, or network-specific instructions. If those details aren’t relayed correctly, approved services can still result in denials. That’s avoidable. 

Which is why clear internal routing, coordination with clinical teams, and reminders about key conditions all matter. Without them, the implementation lags.

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7. Tracking What Works and What Doesn’t

Most organizations finish the authorization process and move on. The best ones ask: What happened here, and how could it go better next time? 

By tracking turnaround time, approval rates, denial reasons, and payer response trends, teams can improve. They can see where requests slow down, which documentation gaps are most common, and where to refine their process.

Turnaround time, Denial rate, and appeal success—they're effective signals. If you're not measuring them, you’ll end up relying on guesswork.

Also, this isn't just optimization — it's risk prevention. And it makes future cycles smoother for everyone involved.

The Bottom Line

Effective utilization management in healthcare requires systematic approaches backed by advanced technology and regulatory expertise. Organizations implementing comprehensive frameworks report quantifiable improvements: up to 95% approval rates, 24-48 hr processing turnaround, and significant reductions in administrative burden.

The seven-step process outlined provides the foundation, but execution remains the key. This is why leading healthcare organizations leverage AI-assisted workflows, EDI-enabled platforms, and real-time analytics to eliminate bottlenecks while maintaining strict compliance with CMS guidelines and payer requirements.

Professional utilization management partnerships deliver immediate capability and sustained optimization. HOM's proven methodology processes 500k+ cases annually with industry-leading turnaround times while maintaining ISO 27001 security standards and comprehensive regulatory compliance. 

Their proactive assessment protocols, optimized technology integration, and patient-centric approach transform authorization challenges into streamlined competitive advantages.

To learn more, contact HOM now.