Utilization Management (UM) has been a familiar term since the 1970s, but its significance has grown considerably as a tool for managing medical costs. The pressure to contain costs amid overutilization and resource waste has intensified, prompting health insurers (payers) and employers to seek ways to control premiums and claims trends. Salesforce Health Cloud for Payers explained.

What started as a rudimentary pre-hospitalization check has evolved into a multifaceted utilization review process involving prospective, concurrent, and retrospective evaluations. Modernizing a decades-old process, addressing fragmented UM systems, and establishing a unified source of truth for care management pose significant challenges.

Enter Salesforce Health Cloud.

Salesforce Health Cloud streamlines care requests, enabling payers to manage precertification and prior authorization efficiently. The Care Request feature in Health Cloud supports various payer UM processes, including prescription drug preauthorizations, service preauthorizations, and admissions review, facilitating informed decision-making and ensuring patients receive necessary care.

  1. For the care management team: Health Cloud enables easy request management, identification of standard vs. expedited requests, real-time status updates, and streamlined workflow management. It allows prioritization of authorization requests and facilitates communication with providers, enhancing operational efficiency and ensuring timely decisions.
  2. For providers: Creating a provider portal within Salesforce Experience Cloud streamlines prior authorization workflows. Providers can initiate authorization requests, attach documentation, track progress, submit additional information, and void authorizations if necessary. This simplifies communication with payers, expedites reviews, and improves overall efficiency. All while being PHI and ePHI compliant.
  3. For members: A member portal provides transparency into the prior authorization process, allowing members to track the status of their requests in real time. This reduces reliance on provider or health plan notifications, enhancing member experience and peace of mind.
  4. For customer service representatives: Health Cloud equips customer service representatives with comprehensive information about authorization statuses, enabling quick resolution of member inquiries. Integrated features facilitate communication with the care management team or providers, ensuring efficient issue resolution.

How Tectonic can help: Tectonic specializes in providing solutions to payers facing UM challenges. Leveraging Salesforce products, we assist health and life sciences clients in maximizing authorizations, creating member service solutions, and deriving actionable insights from captured data. With our industry expertise and tailored consultation, we offer a blueprint for success across all functional areas within payer organizations.

Discover how Tectonic can empower your organization to overcome UM challenges and achieve operational excellence. Contact us today.

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