Research Highlights Utilization Management’s Role in Promoting Evidence-Based Medical Interventions, Cost Containment Efforts and Patient Protections

RegQuest Releases Comprehensive Study Focusing on Regulatory Trends

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RegQuest™, one of the nation’s premier online regulatory compliance resources focusing on medical management and insurance functions, has released the Utilization Management Regulatory and Market Trends: 2016 Annual Report. The UM Trend Report is the first update on the topic in over a decade and the research reveals several interesting trends pertaining to utilization management (UM) programs. The new report confirms the valuable role that UM practices play in the delivery of medicine and the allocation of health care resources, but also sets forth a number of challenges for the future.

“In the post-Affordable Care Act landscape, health plans and medical management organizations are required to comply with several new key regulations, as well as traditional state and federal requirements covering utilization management and similar functions in managed care settings.  Compliance with these regulations remains a significant challenge due to today’s complex regulatory and business landscape,” notes RegQuest Founder and President, Garry Carneal, JD, MA. “However, UM interventions that are quality-based can ensure that patients receive appropriate care at the right time, along with limiting unnecessary medical utilization and costs.”

Carneal continues, “Over time, utilization management programs have consistently been used as a way to promote evidence-based treatments, reduce unnecessary medical treatments, and improve patient safety. While these practices are critically important, the RegQuest team discovered that academic research focused on UM practices has been sporadic over time and several key regulations have not been updated in years. So it might be time to initiate some policy discussions about how to best update payer-based UM programs.” The UM Trend Report highlights that mental health parity is one area where UM systems need to be re-evaluated and potentially upgraded to ensure that the medical management system can support new federal and state laws that are attempting to create more equitable reimbursement policies between behavioral and medical coverage.

In order to fill this information gap, promote regulatory compliance and generate important policy discussions regarding the medical management system, RegQuest published the Utilization Management Regulatory & Market Trends: 2016 Annual Report last month.


The study traces the history of UM practices and found that this form of “peer review” has evolved from a linear transaction looking at actuarial guidelines to a much more dynamic evaluation that factors in evidenced-based medicine, molecular profiling and other emerging medical interventions. Today, these practices are also used to improve quality outcomes for patients. For example, national accreditation agencies such as NCQA and URAC have expanded their UM standards to require quality improvement initiatives that are developed, implemented, monitored and tracked. As such, the return on investment (ROI) for UM programs has evolved to consider not only peer reviewing medical utilization levels, but also clinical indicators and outcome measures.

The Utilization Management Regulatory & Market Trends: 2016 Annual Report is an indispensable resource to help a range of stakeholders navigate today’s complex regulatory and insurance environment.  The UM Trend Report also will stimulate public policy discussions on the next generation of UM best practices and regulatory compliance efforts.

For more information regarding the UM Trend Report, including a complimentary six-page Executive Summary, click here. Copies of the full-length 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, quick-reference tables and receive email alerts to any updates that impact UM stakeholders. 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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