Utilization Review Benchmarking and Clinical Trigger Expansion Delivered 12.5x Results

Large-Scale Benchmarking Revealed a 12.5x Cost Containment Opportunity for Auto No- Fault Payer

The Challenge

Michigan auto no-fault payers face relentless pressure to control medical spend while keeping claims moving. Since Michigan’s 2019 no-fault reforms, many payers have seen meaningful progress, yet billing patterns and treatment utilization continue to evolve. Payers need scalable, consistent, defensible cost containment solutions that do not require additional investment, overhead, or increase potential disputes.

The Approach

When a leading Michigan auto payer was looking for additional ways to control medical spend, Enlyte drew on its broad Michigan auto book of business to benchmark performance across programs. Using the proprietary benchmarks, Enlyte’s team identified a mature peer program using a more active clinical trigger methodology with strong long-term defensibility.

A deeper dive into the data showed the same rule methodology used in another Michigan auto program resulted in only one deposition in five years. 

Because this rule methodology was already proven, the payer partnered with Enlyte to apply the logic to their program philosophy and workflow and deployed it within the utilization review platform to route more high-impact bills into retrospective clinical review.

Rather than one-time rule updates, the engagement took continuous focus on configurable, iterative improvements aligned to real workflows, using ongoing performance data and stakeholder input. The approach included:

Program insights and targeted optimization

• Program baseline: About 2% of the payer’s bills were being routed to nurse review vs. about 20% in a more active peer Michigan auto program.

• Referral driver: Based on internal program trends, the duration-of-care rule drives 76% of utilization review referrals.

• Targeted optimization: Enlyte expanded duration criteria to capture more high-impact utilization patterns for clinical evaluation, while maintaining consistent clinical rationale and documentation standards.

The Results

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.