Physicians complete an average of 40 prior authorizations a week, consuming 13 hours of physician and staff time, according to the 2025 AMA Prior Authorization Physician Survey. That’s the most visible side of utilization management in healthcare.
Utilization management in healthcare is the process health plans, review organizations and hospitals use to decide, case by case, whether a medical service is necessary and appropriate before, during or after it’s delivered.
The term has a second, unrelated meaning in hospital finance and IT: checking whether the phones, tablets, lines and circuits a health system pays for each month are actually in use. Different teams run the two, different rules govern them, and different records prove them.
RadiusPoint, a telecom expense management (TEM) firm in business since 1992, works only on the second kind, auditing telecom, wireless and utility invoices against real inventory in its ExpenseLogic platform. It doesn’t provide clinical utilization management, prior authorization or medical necessity review.
Key Takeaways
- Clinical utilization management reviews medical necessity before care (prior authorization), during an inpatient stay (concurrent review) and after care (retrospective review).
- Since January 1, 2026, CMS generally requires Medicare Advantage, Medicaid and CHIP payers to decide urgent prior authorization requests within 72 hours and standard ones within seven calendar days.
- Device and line utilization review asks a billing question instead: is anyone using the phone, tablet or circuit on this month’s invoice?
- Hospital employee turnover reached 18.5% in 2025, according to NSI Nursing Solutions, and each departure can leave a line billing.
- In one published RadiusPoint case, a healthcare provider cut telecom expenses 26% after unused lines were verified and removed. It’s one client’s result, not an average.
The Short Version
If you need prior authorization or medical necessity review, that’s a job for a health plan or a clinical utilization management vendor; if you’re paying for devices and lines nobody uses, you need a line-by-line utilization review of the invoice.
Clinical utilization management and device utilization review answer different questions
Clinical utilization management asks whether a patient’s care is medically necessary, while device utilization review asks whether a billed line or device is in use. They share a word, not a regulator, a data source or a vendor category. The table below compares them on the points that decide who should own each one.
| Point of comparison | Clinical utilization management | Device and line utilization review |
|---|---|---|
| Core question | Is this care medically necessary for this patient? | Is anyone using this line or device? |
| Who does it | Health plans, their delegated review organizations, hospital review committees | Telecom, IT and finance teams, often with a TEM provider |
| When it happens | Before care, during an inpatient stay, after care | Before an order, every billing cycle, and in audits of past invoices |
| Rules and standards | CMS rules including CMS-0057-F, 42 CFR 482.30 for hospitals, voluntary NCQA accreditation | Carrier contracts and internal wireless, offboarding and approval policies |
| Evidence used | Medical records and written clinical criteria | Carrier invoices and usage, the HR roster, the device and site inventory |
| Possible outcomes | Approval, denial with a specific reason, appeal | Keep, reassign, suspend or disconnect, plus billing disputes |
The timing lines up: an ordering approval workflow mirrors prior authorization, the monthly usage and roster check mirrors concurrent review, and an invoice audit mirrors retrospective review. The stakes don’t. One decision governs a patient’s access to care, and the other governs what the organization pays a carrier.
How does clinical utilization management work before, during and after care?
Clinical utilization management runs in three stages: prior authorization before care, concurrent review during an inpatient stay, and retrospective review after care is billed. Each stage applies written clinical criteria to one patient’s case, and each can end in approval, a request for more information, or a denial the provider can appeal.
- Prior authorization, also called precertification or prospective review, happens before a planned service. The payer approves the request, denies it or asks for more documentation.
- Concurrent review happens while a patient is admitted. It checks whether continued inpatient care still meets criteria.
- Retrospective review happens after care is delivered and billed. It confirms the care was appropriate and given at the right level.
The Institute of Medicine’s 1989 report, Controlling Costs and Changing Patient Care?, described utilization management as techniques that purchasers of health benefits use to control costs by reviewing, case by case, whether care is appropriate before it’s provided. Under 42 CFR 482.30, a hospital in Medicare and Medicaid must keep a utilization review plan run by a committee of two or more practitioners, unless a Quality Improvement Organization has assumed binding review. So one admission can be reviewed twice: by the hospital and by the patient’s health plan.
Which federal rules and standards shape utilization management in 2026?
CMS sets prior authorization deadlines for Medicare Advantage, Medicaid and CHIP payers, hospital rules require review plans, and NCQA accreditation adds voluntary standards. The CMS Interoperability and Prior Authorization final rule, CMS-0057-F, matters most this year, because its first operational deadlines took effect on January 1, 2026.
| Provision | What CMS-0057-F requires | Compliance date |
|---|---|---|
| Decision timeframes | 72 hours for expedited (urgent) requests and seven calendar days for standard requests; Qualified Health Plan (QHP) issuers on the Federally Facilitated Exchanges are excluded | Generally January 1, 2026 |
| Denial reasons | A specific reason for every denied request | Generally January 1, 2026 |
| Public metrics | Prior authorization metrics posted annually on the payer’s website | First report by March 31, 2026 |
| Prior Authorization API | A FHIR-based interface for electronic requests, documentation requirements and decisions | Generally January 1, 2027 |
The rule covers medical items and services, not drugs, and KFF notes it cut the standard response window from 14 calendar days to seven. For healthcare utilization management organizations, NCQA’s Utilization Management Accreditation is the voluntary layer. It checks quality improvement, member confidentiality, use of appropriate professionals, fair and timely decisions and appeals handling, and NCQA says more than 50 organizations hold it.
Why prior authorization draws scrutiny from physicians and policymakers
Prior authorization draws scrutiny because request volume keeps climbing, most appealed denials are overturned, and physicians link the process to delayed and abandoned care. Medicare Advantage insurers received nearly 53 million prior authorization requests in 2024, up from 49.8 million in 2023, according to a KFF analysis of data insurers report to CMS.
Insurers denied 4.1 million of those requests, or 7.7%. Only 11.5% of denials were appealed, but 80.7% of appeals were fully or partially overturned. In the 2025 AMA survey of 1,000 practicing physicians, 95% said prior authorization delays access to necessary care and 26% said it had led to a serious adverse event. About 60 insurers pledged in June 2025 to simplify the process, yet only 33% of those physicians expect a meaningful difference. The cost pressure behind it is real: CMS puts 2024 U.S. health spending at $5.3 trillion, up 7.2% and equal to 18.0% of GDP.
What does utilization review mean for hospital phones, tablets and lines?
In hospital telecom, utilization review means matching every billed device or line to a current user, site and purpose, then acting on each mismatch. It’s a cost and asset question with no clinical judgment involved, and its evidence comes from carrier invoices, the HR roster and the device inventory rather than medical records.
Workforce churn feeds the problem. The 2026 NSI National Health Care Retention and RN Staffing Report, covering 527 hospitals, put 2025 hospital employee turnover at 18.5% and found that 29.5% of new hires left within a year. Over five years, the average responding hospital turned over 106% of its workforce. Each departure that leaves a device behind keeps billing until offboarding reaches the carrier. Scale multiplies it: the American Hospital Association counts 397 U.S. health systems holding 4,157 hospitals.
That reconciliation is the only utilization work RadiusPoint does. RadiusPoint analysts compare carrier bills against an inventory of employees, devices and sites in ExpenseLogic, auditing every line item rather than a sample. RadiusPoint doesn’t offer clinical utilization management or make medical necessity decisions.
Seven checks that catch unused devices and lines before the next invoice
A health system can find unused devices and lines with seven checks, each tied to a capability the RadiusPoint team already runs inside ExpenseLogic. The checklist below lists what each check catches and which ExpenseLogic capability performs it, so you can test your own process line by line.
| Check | What it catches | ExpenseLogic capability |
|---|---|---|
| 1. Zero use | No voice, data or text activity in the review window | Zero-use device identification |
| 2. Roster match | Lines assigned to people who’ve left the organization | Ex-employee line detection through HR roster reconciliation |
| 3. Registration | Numbers no current employee will claim | Annual line registration |
| 4. Ownership | Smartphones, tablets and wearables with no serial number or Employee ID match | Device inventory by serial number and Employee ID |
| 5. Site status | Lines and circuits billing at a closed clinic, wing or office | Closed-location billing exception reports |
| 6. Post-cancellation charges | Services still billing after a disconnect order | Line-item audit against contracted rates and inventory |
| 7. Purpose | Quiet lines serving fire alarm panels, elevator phones or other building systems | Client-defined approval workflows on MACD (move, add, change, disconnect) tickets |
Run the roster match before acting on zero use: a quiet line with a current owner needs a conversation, while one with no owner is a disconnect candidate. The method for both checks is in our walkthrough on finding and retiring zero-use mobile lines. The seventh check matters most in hospitals, where a line can sit silent for months and still be required. Our guide to healthcare telecom expense management covers how health systems tier life-safety circuits before any change.
One healthcare operator cut telecom expenses 26% by verifying which lines were in use
RadiusPoint’s published healthcare case shows a 26% reduction in telecom expenses for one provider after its unused business lines were verified and removed. It’s a single client’s result, not an average across clients, and the method behind it is what transfers to other health systems.
The client ran assisted living and nursing home sites with no prior telecom inventory or audit. RadiusPoint verified each line with test calls and, where nobody answered, site visits, then removed the dormant lines from the invoices. The audit also caught charges for services canceled years earlier. The full account is in the published healthcare telecom case study.
Two other published results are relevant. A healthcare AP and ordering automation engagement returned a 448% ROI, also a single case. And one multi-location client was paying $1,500 a month, $18,000 a year, for utilities at closed locations, the same problem on Utility Expense Management (UEM) invoices. RadiusPoint has been in expense management since 1992. Amalgam Insights named it a Distinguished Vendor in its 2024 TEM Vendor SmartList, and ExpenseLogic holds a 4.8 Capterra rating from 31 reviews.
Which utilization problem should your team solve first?
Solve the problem your team actually owns: payer and clinical teams own medical necessity review, while finance, IT and telecom teams own billed device utilization. If your question is about prior authorization, the CMS rule and your payer contracts are the place to start.
If your question is why the telecom bill doesn’t match the devices your staff carry, start with one month: pull every billing account, match each line to this month’s HR roster and flag anything billing at a closed site. Every month that check doesn’t run, the same charges post again. See the full scope of RadiusPoint’s telecom expense management services.
Frequently asked questions
Is utilization review the same thing as utilization management?
Close, but not identical. StatPearls notes that utilization management was originally called utilization review. Today, utilization review usually means the case-level check of one admission or service, while utilization management means the wider program of criteria, staff and appeals around it. Federal hospital rules at 42 CFR 482.30 still use the older term.
Who decides whether a prior authorization request gets approved?
The health plan decides, directly or through a utilization management organization working for it, using written clinical criteria. NCQA accreditation checks that appropriate professionals make those decisions. Physicians doubt it happens reliably: in the 2025 AMA survey, only 24% said medical necessity denials are consistently reviewed by appropriately qualified clinicians.
Does RadiusPoint handle prior authorization or medical necessity review?
No. RadiusPoint is a telecom, wireless and utility expense management firm, and it doesn’t provide clinical utilization management, prior authorization or medical necessity review. Its utilization work is financial: RadiusPoint analysts use ExpenseLogic to find devices, lines and services a health system still pays for after the user or site is gone.
How often should a health system review device and line usage?
Monthly for usage and HR roster matches, since both change every billing cycle, plus a yearly line registration that makes every user confirm their number. With hospital employee turnover at 18.5% in 2025, according to NSI Nursing Solutions, an annual-only check would leave up to twelve months of departures unreconciled.
References
- American Medical Association, AMA survey: Prior authorization reform pledge falls short with physicians (2025 AMA Prior Authorization Physician Survey), May 13, 2026.
- Institute of Medicine, Controlling Costs and Changing Patient Care? The Role of Utilization Management, National Academies Press, 1989.
- StatPearls Publishing, Utilization Management, NCBI Bookshelf, 2025.
- California Health Benefits Review Program, Explainer: Utilization Management: An Overview, January 2026.
- Code of Federal Regulations, 42 CFR 482.30, Condition of participation: Utilization review, via Cornell Legal Information Institute.
- Centers for Medicare and Medicaid Services, CMS Interoperability and Prior Authorization Final Rule CMS-0057-F (fact sheet), January 17, 2024.
- National Committee for Quality Assurance, Utilization Management Accreditation Requirements and Utilization Management Accreditation FAQs, accessed October 2026.
- KFF, Medicare Advantage Insurers Made Nearly 53 Million Prior Authorization Determinations in 2024, January 28, 2026.
- Centers for Medicare and Medicaid Services, NHE Fact Sheet (National Health Expenditure data for 2024), 2026.
- NSI Nursing Solutions, 2026 NSI National Health Care Retention and RN Staffing Report, March 2026.
- American Hospital Association, Fast Facts: U.S. Health Systems 2025 Infographic, June 2025.
- RadiusPoint, Healthcare Case Study: Telecom Expenses Down by 26% in Healthcare, December 2023 (linked above).
- RadiusPoint, AP/Ordering Process Automation Nets 448% ROI, case study, 2019.
- RadiusPoint, Vacant Cost Recovery: The Utility Bills Nobody Is Watching, August 2026.
- Amalgam Insights, 2024 Telecom Expense Management Vendor SmartList.
- Capterra, ExpenseLogic reviews, accessed October 2026.
This page provides general information about utilization management for reference only and isn’t clinical, regulatory or legal guidance. RadiusPoint does not provide clinical utilization management, prior authorization or medical necessity review services. Case results describe specific published RadiusPoint engagements and don’t guarantee results for other organizations.