Improving Healthcare Utilization Management

Today’s consumers demand greater visibility, accuracy, and control over their healthcare information and options. Yet navigating the healthcare journey is often confusing and frustrating for patients. Everything from finding out what providers are in-network, determining which services are medically necessary, and sorting out payments between payers and providers can be unclear and fraught with error.

With the technological disruption that has taken almost every industry by storm, patients expect the healthcare organizations they rely on to operate seamlessly. This makes it more important now than ever for healthcare organizations—payers and providers—to unify pertinent data, optimize their operations, and effectively manage the patient experience.

However, this is easier said than done.


Many healthcare organizations have yet to fully digitally transform their business and are still operating in siloed systems with legacy applications and manual business processes.

This is costly and time-consuming to the organization and frustrating to the patient. For payers, inaccurate information could cost millions of dollars in payouts, and providers risk losing their patients to other facilities with better and more modern capabilities.


Appian, the Digital Transformation Platform™, allows information from disparate systems to be integrated and actionable in one location. Both payers and providers can share information regarding services, coverage, and more.

This in turn makes it possible for utilization management, a challenge for so many healthcare organizations, to be effectively and efficiently achieved. With advanced integration capabilities that break down silos and aggregate all data into a single repository, healthcare providers gain visibility to accurately determine the necessity for services and coordinate with payers to sort out insurance coverage. Then, business rules can be applied to automatically determine escalations and approvals.

The result? Patients can confidently receive care without worrying about whether they are truly covered, and providers retain their customers. Payers benefit as well, saving time on pre-authorization approvals while reducing errors. The overall process becomes significantly more agile and efficient.


Effective utilization management automation—and overall digital transformation—is mandatory if your healthcare organization plans to thrive. The Appian solution to these business challenges can save time and operating costs while maintaining and growing your member ranks. Learn more about how Appian can help in Optimizing Healthcare Utilization Management.


Fritz Haimberger

Vice President, Healthcare Provider Practice