U.S. healthcare organizations are under mounting pressure to control costs, address workforce shortages, improve patient outcomes, and meet evolving regulatory requirements. Yet, many utilization management (UM) processes remain rooted in manual reviews and retrospective decision-making, impeding efforts to improve outcomes at a sustainable cost. These pressures are driving demand for a more coordinated and proactive approach to utilization management and member care.
Specifically, organizations have an opportunity to move UM beyond transactional authorization processes and administrative gatekeeping toward a “Four Rights” framework: delivering the right care to the right member at the right time, and at the right cost. This emerging UM model combines operational intelligence, clinical expertise, and intelligent workflows to answer four critical questions:
- Are we identifying the right members for intervention in collaboration with providers?
- Are they receiving the right care?
- Are we engaging with the member at the right time?
- Are they receiving care at the right cost?
Aligning on these four dimensions can better position health plans to improve outcomes, optimize resources, and advance their strategic care management objectives.
1. Right Member: Identification and Stratification
Effective UM begins with knowing where clinical attention can have the greatest impact. Rather than applying the same review processes across broad populations, organizations can use clinical information, claims data, pharmacy data, and social data to improve their understanding of member needs and prioritize resources where they can have the greatest impact.
Predictive analytics and stratification models help uncover risks earlier, enabling proactive outreach and interventions that reduce avoidable utilization, prevent worsening health conditions, and close gaps in care. Combined with clinical expertise, these insights enable earlier intervention and more targeted care management strategies. The goal is not simply to identify high-cost members, but to connect the right individuals with appropriate support before costs escalate and outcomes suffer, while also identifying members at medium or lower risk whose health trajectories indicate a greater likelihood of becoming high-risk and high-cost.
2. Right Care: Clinical Appropriateness and Evidence-Based Decision Making
Once high-risk members and utilization opportunities are identified, UM must help ensure that care is clinically appropriate and evidence-based. This work requires moving beyond authorization processes focused primarily on administrative review and approval toward more intelligent, evidence-based decision support that helps ensure clinical appropriateness.
Authorization is evolving from a largely manual process to one that is increasingly automated, evidence-driven, and clinically intelligent. However, technology does not replace clinical judgment. Rigorous clinical review remains central to ensuring that care decisions are appropriate, personalized, and aligned with best practices. By combining evidence-based guidelines, experienced clinical reviewers, and collaborative provider engagement, organizations can reduce unwarranted variation and support more consistent care decisions. An example of right care is recommending home infusion instead of hospital-based infusion when clinical outcomes are comparable and the home setting is appropriate. The home setting is also more appropriate for the comfort of the member and decreases the risk of hospital-acquired infections.
Provider education and peer-to-peer collaboration further strengthen alignment around best practices, helping to ensure that UM serves as a tool for improving care quality rather than simply managing requests.
3. Right Time: Proactive Intervention and Care Transitions
Even the most appropriate care can lose value if it is delivered too late. High-performing UM that follows the new model focuses not only on what care members receive, but also when interventions and treatments occur.
Timely intervention depends on recognizing emerging risks before they become costly clinical events. For example, a member with uncontrolled type 1 diabetes who has recently been discharged from the hospital may be showing gaps in medication adherence, decreased knowledge of their condition, missed follow-up appointments, and challenges related to social determinants of health, such as limited transportation, inability to afford required prescriptions, or food insecurity. By flagging these warning signs early, care teams can coordinate a smoother transition to outpatient care, provide targeted outreach and support services, and help prevent avoidable complications or readmissions.
The stakes are significant. According to the most recent economic analysis from the American Diabetes Association, published in 2024, people diagnosed with diabetes incur annual health care expenditures of approximately $19,700 per person, and the total economic burden of diagnosed diabetes in the United States is estimated at $412.9 billion, including $306.6 billion in direct medical costs and $106.3 billion in indirect costs.1 These findings highlight the value of early interventions that help prevent disease progression, reduce avoidable utilization, and improve long-term outcomes.
The goal is to move from reactive utilization review to timely, targeted intervention. By engaging members at critical points in their care journey, organizations can improve outcomes, reduce unnecessary care, and make better use of limited clinical resources.
4. Right Cost: Value, Site-of-Care, and Network Optimization
Even when the right members receive the right care at the right time, organizations must continue to ensure healthcare resources are used wisely. Cost management remains an essential objective, but the new model of effective UM approaches cost through the lens of value rather than restriction. The goal is not to reduce utilization indiscriminately, but to ensure resources are used in ways that support evidence-based guidelines, quality, and efficiency.
Operational intelligence plays a critical role in achieving this balance. By analyzing utilization patterns, provider performance, and care delivery trends, organizations can identify opportunities to route care to the most appropriate setting, reduce unnecessary variation, and improve network performance. These insights help ensure that members receive care in the right environment, while enabling more effective allocation of clinical and financial resources.
For example, when advanced imaging is clinically appropriate, directing a member to an independent imaging center rather than a hospital outpatient department can provide the same diagnostic quality at a lower cost. Similarly, directing members to high-performing providers with demonstrated quality outcomes can improve both value and care quality. When combined with clinical expertise and intelligent workflows, this approach shifts the focus from cost containment alone to better stewardship of healthcare resources.
Putting the Four Rights into Practice
The future of utilization management is not defined by how quickly organizations approve or deny requests. It is defined by how effectively they identify the right members, support the right care, intervene at the right time, and achieve the right cost and quality outcomes.
Sagility helps health plans operationalize the Four Rights through a combination of operational intelligence, embedded clinical expertise, and intelligent workflow automation. CoreIQ provides the intelligence needed to identify opportunities and guide decisions, while SmarTec helps translate those insights into action across the UM lifecycle. Sagility Synchrony uses operational signals and business rules to prioritize work, route exceptions, align dependencies, and provide end-to-end execution visibility.
Combining these solutions with embedded clinical expertise and end-to-end UM management helps health plans align around the Four Rights framework. The result is a more proactive, efficient, and member-centered approach to UM that improves outcomes, strengthens collaboration, and supports more sustainable healthcare delivery.
