Why Health Plans Are Reclaiming Utilization Management, and What It Takes to Do It Right

For years, utilization management (UM) was quietly delegated away for scale, speed, and supposed efficiency. But today, health plans are hitting the breaking point.

Prior authorizations, a core function of UM, have become synonymous with administrative gridlock. Providers are overwhelmed. Members are frustrated. Regulators, including the Centers for Medicare & Medicaid Services (CMS) through the Final Rule CMS-0057-F , are intervening. Even the industry’s own trade group, AHIP, has acknowledged the problem with a collective pledge to modernize prior authorization.

What’s emerging isn’t just a call for reform; it’s a clear shift in strategy: reclaim control, intelligently.

Delegation solved yesterday’s problems but introduced today’s

Delegating UM to vendors once made sense. Health