How a delegated-UM IPA hit $4.40 cost per approved auth.
When a delegated UM operation has to pass NCQA audit, generate quarterly reporting, and clear a million-plus annual cases on a budget that is contractually capped, the only path is industrial-grade automation with a real reviewer console behind it.
What was broken, in dollar terms.
Took delegated UM from two regional Medicare Advantage plans in 2024. The economics worked on paper. By Q3 2025 they did not work in practice.
- Manual UM operation cost of $1.74M/year against a contracted UM cap of $1.50M
- NCQA UM accreditation re-survey scheduled for Q2 2026 with two findings open from the prior cycle
- Throughput plateaued at 8,200 cases/month against a contracted volume of 10,500/month — the IPA was paying overflow penalties to one of the plans
- Reviewer staffing model dependent on three contract LPNs whose retention had become the single point of failure
The integration, the workflow change, the 90-day arc.
The pilot replaced the manual workflow with a delegated agentic pipeline plus a reviewer console where the IPA's own clinical leadership owns adjudication. Not a black box: every decision is auditable and every reviewer override is logged into the NCQA file.
- Delegated UM workflow with the IPA's medical director as the named reviewer-of-record on every case
- Reviewer console exposes the criteria trace, the source policy excerpt, and the supporting EHR evidence in a single screen — reviewer median time-to-decision dropped from 11 minutes to 90 seconds
- Gold-card eligibility surfaced per physician per CPT category — 64% of the IPA's network qualified for gold-card status on at least one category within 60 days
- NCQA UM audit file generated automatically every quarter: case-level decision rationale, criteria citations, reviewer attestations, all in the NCQA submission format
The seven seeded categories, by the numbers.
Pilot ran across the seven CPT categories that, in combination, accounted for roughly 62% of the customer’s PA volume. Auto-approval rates reflect the share of cases that cleared without human review under the customer’s own medical-policy library.
| CPT | Category | Auto-approval | P50 latency | Weekly volume |
|---|---|---|---|---|
| 72148 | MRI lumbar spine | 76% | 24s | 168/wk |
| 27447 | Knee arthroplasty | 62% | 36s | 58/wk |
| 78815 | PET/CT skull-to-thigh | 70% | 30s | 42/wk |
| 96413 | IV chemotherapy admin | 83% | 20s | 138/wk |
| 90867 | TMS therapy | 58% | 42s | 28/wk |
| J9271 | Pembrolizumab inj. | 81% | 22s | 88/wk |
| E2102 | DME — CGM sensor | 87% | 18s | 182/wk |
“We can pass an NCQA UM audit on a Tuesday because Authora generated the file on Monday. That is not a marketing line. That is what the auditors actually look at.”
Year-one expansion plans.
- Renew both delegated-UM contracts at materially improved unit economics for 2027
- Expand to one additional Medicare Advantage plan in the same market for 2027
- Open the reviewer console to the IPA's affiliated specialist groups under a shared-tenant model
- Co-author the NCQA UM Accreditation case study with NCQA's policy team
The trust posture is the same as the pilot.
Every pilot runs under BAA, in us-east-2, with the same SOC 2 Type II + HITRUST r2 posture documented in /trust. The pilot economics are documented in /pilot.