UM & PA
Utilization management
Prior auth performance, peer-to-peer outcomes, and denial patterns — by payer, by service line, by provider.
Open PA requests
118
Avg approval time
2.4 d
Denial rate
11.8%
Overturn on appeal
62%
Top denial drivers
- actionMRI lumbar w/o trial of PTAetna · 28 cases · 92% overturn
- actionGLP-1 for non-T2DMMultiple · 41 cases · medical necessity
- actionInpatient obs → admit conversionUHC · 14 cases · LOC criteria
- actionDME — CGM for non-insulin T2DMCigna · 22 cases · policy change
Peer-to-peer outcomes (30d)
P2Ps scheduled47
Approved post-P2P31
Avg P2P duration12 m
MD time reclaimed via templates18 h
Gold-card opportunities
- Dr. Patel · imaging98% approval · eligible
- Dr. Liu · ortho surgery96% · eligible
- Dr. Reyes · oncology infusions92% · candidate
- Group total est. savings$210k / yr