New Study Reveals Need for Increased Transparency of Medical Necessity Determinations

RegQuest Releases Comprehensive Report Focusing on Utilization Management

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RegQuest™, one of the nation’s premier online regulatory compliance resources focusing on medical management and insurance functions, announces the release of the Utilization Management Regulatory & Market Trends: 2016 Annual Report (UM Trend Report). The report, based on a detailed regulatory survey, academic research and expert interviews, provides a comprehensive overview of utilization management (UM) regulations, trends and practices.

As the first update on this topic in over a decade, the report is a must-read for anyone interested in learning and tracking how the U.S. health care system regulates UM programs, both at the state and federal levels. The study was sponsored by EBG Advisors and Schooner Strategies.

“Many health plans use utilization management programs as a cost containment measure to help control health care expenses along with ensuring that right level of coverage is authorized for patients,” notes RegQuest Founder and Lead Researcher, Garry Carneal, JD, MA. “A predominant trend throughout the research is the need for more transparency and disclosure in how medical necessity decisions are made.”

“The UM Trend Report illuminates the complex web of rules, policies and practices that affect how medical care is actually paid for and who is impacted in the process. Significantly, the report highlights how patients and attending providers appeal adverse benefit determinations,” remarks Bob Atlas, MBA, President of EBG Advisors.

The report also covers a number of additional issues related to UM programs including litigation trends and information on the next generation of UM practices, such as incorporating evidence-based medicine and mental health parity requirements.

“Many aspects of the utilization management industry are undergoing tremendous changes and innovation,” states David Nixon, CEO of InformedDNA. “More ‘high-touch’ utilization management programs that cover genomics and molecular aspects of medicine is but one example where greater fidelity is required when making coverage determinations.” Mr. Nixon is one of the experts interviewed by the research team for this study.

Carneal adds, “It is our hope that the Utilization Management Regulatory & Market Trends: 2016 Annual Report will not only serve as a helpful guide to navigate this complex regulatory environment, but that it will also stimulate public policy debate to identify best practices in terms of compliance with regulatory requirements and updates to key medical management practices by payers.”

For more information regarding the UM Trend Report, including a complimentary six-page Executive Summary, click here. Copies of the comprehensive UM Trend Report are available to paid subscribers of RegQuest’s Utilization Management Module. Purchasers of the UM Module also have access to RegQuest’s comprehensive database of UM state laws and regulations. In addition to the UM Trend Report, subscribers have access to other industry resources and will be alerted to any updates that might affect the UM industry. To subscribe, please visit

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About RegQuest (

RegQuest, Your Regulatory Compliance Resource, details many of the business, legal and regulatory forces directly impacting the medical management system, including requirements adopted under the Affordable Care Act. In addition, the guide serves as the definitive resource of detailing how regulatory and business trends are affecting medical management practices. RegQuest was created in conjunction with Schooner Strategies and EBG Advisors with private funding.

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