Health plans must rethink UM: WNS HealthHelp’s AI-driven approach is a path forward

Utilization management (UM) helps health plans decide if a medical service is necessary before they agree to pay for care. It has been evolving over time to reduce cost, improve efficiency, and, according to some, improve health outcomes. WNS HealthHelp has been pushing the boundaries for innovation in this space with its platform CONSULT^TM, providing augmented support across several clinical areas. WNS HealthHelp incorporates practicing physicians and their real-world expertise across all clinical domains, including the cardiology, musculoskeletal, oncology, radiology, and sleep therapy domains, delivering healthy outcomes while being flexible (see Exhibit 1) in engaging with health plans.

Exhibit 1: Multiple options to engage partners are key to ensuring the right fit for health plans

Source: HFS Research, 2025

The approach to utilization management is evolving again

The acceleration of electronic health record (EHR) systems due to Meaningful Use regulations changed how UM was conducted—going from a manual, inconsistent, and lengthy cycle time to a greater level of automation that rendered highly consistent evaluations.

However, as cost of care escalated—due to increased demand driven by expanded access, disease prevalence, and the influence of pharmacy benefit managers (PBM)—UM had to evolve. It now addresses the volume of requests, speed to evaluation, and the need to incorporate an extensive range of medical literature into decisioning.

The new UM solution comes at time when authorization requirements have risen sharply. Health plan benefits increasingly need prior authorizations before treatment is given. The number of prior authorizations (PA) more than tripled from 2005 to 2023 (an estimated 50 million PAs processed just for Medicare in 2023 alone).

Moreover, slow UM and delayed PA have led to treatment delays, a higher propensity for adverse events, and more consumers abandoning medical care. As a result, AI is being leveraged to play a critical role—make UM faster, consistent, less expensive, and better equipped to reduce fraud, waste, and abuse.

There are several big-league options in the market, including Carelon, EviCore, and Evolent. These companies claim to work against the grain to improve traditional UM, but the results are patchy at best.

AI-enabled solution forces health plans to think 21st century UM

WNS HealthHelp is embracing the possibilities of AI to tackle the endemic challenges of UM and PA, particularly the inefficiencies and delays in seeking approval for diagnostic imaging and other medical services. CONSULT^TM streamlines processes by integrating AI and automated workflows that accelerate and improve the accuracy of medical necessity determinations. By leveraging generative AI technology, WNS HealthHelp incorporates virtual clinical agents to improve speed, accuracy, and ultimately quality by allowing clinicians to focus on the most challenging cases.

WNS HealthHelp’s approach to addressing the UM/PA space through CONSULT^TM. has three key attributes:

• A modular approach: WNS HealthHelp meets its clients where they are with various models (see Exhibit 1). It can offer fully outsourcing UM (delegated) or augment existing processes (BPO/BPM, partial delegation) with modular clinical and non-clinical services (such as clinical reviews, call centers, or intake support). It takes full responsibility for the prior authorization process—from intake to decision-making in the delegated model. With the partial delegated model, health plans can leverage the platform’s expertise while maintaining some control over the authorization process.
• The power of AI: WNS HealthHelp considers AI as an augmenting force rather than a fully autonomous decision-maker for its UM solution. The solution is designed to support three core objectives: maintain clinical integrity of the program to ensure best care for members, improve the provider experience with UM, and meet all stakeholder concerns on security and compliance. It leverages AI to analyze clinical documentation and match it against established medical criteria. This allows for quicker decision-making, often resulting in approvals within minutes instead of days. It also enables customization to address health plan-specific needs and workflows, with rules engines supporting flexible configurations.
• Collaborative care model: CONSULT^TM facilitates communication between healthcare providers and clinical reviewers, enabling a consultative approach early in the UM process instead of addressing the situation as an appeal post-rejection. This collaboration helps clarify the reasons for requests, leading to better outcomes such as reduced denials and improved treatment pathways.

Outcomes, not hype, are what matter

WNS HealthHelp’s CONSULT^TM has delivered tangible outcomes for providers, patients, and their health plan clients on key performance metrics such as experience, turnaround times, and denial rates. Some notable impacts are:

• 70% reduction in wait decision time
• Over a 60% decrease in time providers spend on authorization
• 50% reduction in calls and faxes, indicating more streamlined workflows
• Net promoter score (NPS) of 60 against the industry average of ~21
• 50% reduction in denial rates

The Bottom Line: AI is transforming UM, but health plan leaders must ensure platforms such as WNS HealthHelp’s CONSULT^TM integrate seamlessly with their existing systems and comply with regulatory requirements.

WNS HealthHelp claimed a strong 70% reduction in decision time among other impacts, health plans must weigh the metrics against potential regulatory hurdles and provider pushback. They should also scrutinize how the platform integrates with their existing EHRs and legacy UM processes. Is WNS HealthHelp truly interoperable, or does it require expensive and time-consuming integrations that dilute ROI? Legacy UM needs a shake, and WNS HealthHelp is a viable option.