Problem
At a large insurance carrier, adjusters were manually tracking utilization review (UR) determinations and cross-referencing them with incoming medical bills, often across multiple claims. Their traditional manual approach to UR was time-consuming, prone to human error and made it difficult to catch when providers billed for services that had previously been denied or exceeded the authorized limits. As a result, they paid for non-authorized treatments and lost productivity as their adjusters had to spend valuable time on administrative tasks instead of higher-priority responsibilities.
Solution
To address the inefficiencies and disconnect between their UR and bill review process, Enlyte introduced Utilization Review Decision Manager (URDM), an integrated solution that seamlessly embeds UR decisions into the bill review platform, SmartAdvisor. URDM applies intelligent logic to evaluate whether billed services are aligned with approved treatment authorizations by automatically approving, denying or flagging bills based on UR outcomes.
$2M in Savings Captured Within One Year
5% of Bill Volume Impacted Through Automation
41% Increase in Bill Review Savings
Outcome
After expanding utilization review trigger rules to mirror a proven peerprogram structure, average monthly treatment reductions increased by 12.5x in the first full months following deployment, helping them achieve additional cost containment of $250,000 in monthly.
In addition to cost containment, the payer also gained confidence from long-term experience with the same rule framework in a separate Michigan auto program, where dispute activity remained exceptionally low over time.