Rising complexity, limited resources: How health plans can close the clinical expertise gap

Health plans are facing a convergence of pressures unlike anything in recent memory. Clinical cases are growing more complex as people suffer from more chronic conditions. Regulatory expectations continue to rise. Finances are under constant scrutiny. And through all of it, plans are expected to maintain trust with the members who depend on them and the providers who deliver care.

At the same time, most plans are being asked to do more with less. Internal clinical teams are stretched across competing priorities such as care management, quality initiatives and utilization management compliance. That leaves limited bandwidth for the kind of deep, specialty-specific clinical review that complex cases demand.

The pressure is real, and it’s measurable. An estimated 85% of payer executives say regulatory pressures are having a direct financial impact on their organizations. More than half of U.S. states have now passed laws mandating the qualifications required of clinical reviewers. And the physician workforce deficit continues to grow, tightening the talent pool.

Clinical review sits at the center of this tension. It’s where clinical integrity, regulatory compliance, financial sustainability, and provider and member satisfaction all intersect. The question isn’t whether plans need high-quality clinical review—it’s whether they have the internal capacity to deliver it at the scale and complexity the current environment demands.

The clinical expertise gap

Many health plans have invested significantly in their operational infrastructure—systems, workflows and compliance frameworks. What’s often missing is the depth and breadth of clinical expertise needed to make sound, defensible and compliant review decisions across the full range of cases that a plan encounters.

That gap shows up in several ways:

• Specialty-match requirements are hard to meet at scale. Clinically sound and defensible review decisions require the reviewing clinician to have expertise in a relevant specialty. Many health plans simply can’t staff board-certified reviewers across the full breadth of specialties and subspecialties they encounter—a range that can span dozens of disciplines.
• Same-state licensure adds another layer of complexity. A growing number of states now require that the clinician conducting utilization management review be licensed in the same state as the ordering physician. For plans operating across multiple states, meeting this requirement internally means maintaining a geographically diverse, multi-state-licensed clinical workforce—a significant compliance and operational challenge that compounds the staffing burden.
• Routine review is only part of the picture. Even plans with some in-house clinical review capability often lack resources for higher-complexity work: appeals, fair hearings, grievance hearings, arbitrations, clinical policy development, and complex case resolution, which require direct clinician-to-clinician engagement. These are the competencies that carry the greatest weight, and they require a level of specialty depth that’s difficult to maintain internally.
• Workforce pressures make the problem harder to solve from within. Recruiting, credentialing, and retaining qualified physician reviewers is increasingly competitive and costly. Plans that attempt to build this capacity internally face ongoing staffing and quality concerns.

When these clinical expertise gaps exist, the downstream consequences compound. Decisions may be delayed, creating care disruptions for members waiting on a determination. Inconsistent or poorly supported decisions are more likely to be overturned on appeal. Audit exposure grows. And over time, these patterns erode the trust that members and providers place in the plan’s review process.

 Why technology alone cannot solve clinical review challenges

Technology platforms have meaningfully improved prior authorization workflows—automating submissions, streamlining routing and reducing administrative burden. That progress is real and valuable, and plans are right to invest in it.

But clinical review decisions, especially complex ones, require human clinical judgment: nuanced interpretation of medical records, specialty-specific knowledge and the ability to engage directly with providers. These are determinations where the clinical context matters as much as the criteria, and where a reviewer’s expertise can make all the difference in reaching an evidence-based, defensible decision that best supports the member.

Regulatory and accreditation standards reinforce this. They require qualified clinicians to be involved in review determinations. Technology can better facilitate the process, route the case, and surface relevant data, but it doesn’t replace the reviewer. The industry continues to emphasize the need to keep experienced clinicians in the decision-making process, particularly for complex cases and adverse determinations.

What to look for in a clinical review partner

For plans evaluating whether to augment their clinical review capabilities through a partner, not all options are equal. The right partner should be able to demonstrate strength across several dimensions:

Depth and breadth of specialty coverage. Can the partner match reviewers to the specific clinical area under review across a wide range of specialties and subspecialties? The ability to consistently provide specialty-matched reviewers is foundational to reaching the right evidence-based decisions.

Same-state licensure capabilities. Can they meet state-level licensure requirements without placing the compliance burden on the plan? As more states enact these requirements, this becomes a critical differentiator.

Full-spectrum clinical support. Can they support not just initial reviews, but also appeals, fair hearings, grievance hearings, arbitrations, clinical policy development and complex case resolution? Plans need a partner equipped for every stage of a clinical determination, from initial review through appeal, hearing and resolution.

A dedicated, accountable clinical workforce. What is the partner’s model for staffing physician reviewers? A workforce that’s dedicated to clinical review—with rigorous credentialing, consistent training and strong quality oversight—delivers a level of consistency and accountability that ad hoc or per diem staffing models typically can’t match.

Proven experience and track record. How long has the partner been delivering clinical review at scale? Depth of experience across plan types, lines of business and clinical scenarios is difficult to replicate.

Accreditation and compliance alignment. Does the partner maintain recognized accreditations, with workflows designed to support regulatory requirements and withstand audit scrutiny? A partner's accreditation status is one of the first things regulators and auditors look for when evaluating how clinical review is being conducted.

Flexible engagement and billing. Can the partnership scale to the plan’s actual needs, with transparent billing models that reflect real usage? Plans shouldn’t have to commit to rigid volume tiers or pay for capacity they don’t use.

Collaborative, tailored solutions. Will the partner work with the plan to design solutions that fit its specific operational, regulatory and clinical needs, rather than forcing a fixed workflow? The best partnerships are built around tailoring review models, communication pathways, reporting and clinical engagement approaches to support the plan’s unique goals.

 How extended clinical solutions supports health plans. The pressures on health plans aren’t easing. Regulatory expectations will continue to grow. Clinical cases will continue to become more complex. And the workforce challenges that make it difficult to build deep in-house specialty review capacity aren’t resolving anytime soon.

Clinical review carries real consequences for members, providers and the plan itself. It deserves dedicated capacity, not whatever bandwidth a stretched internal team can spare. The right clinical review partner extends a plan’s capabilities without adding operational complexity, filling expertise gaps, supporting compliance and ensuring that every determination meets the highest standard.

EviCore by Evernorth’s Extended Clinical Solutions (ECS) was built to address exactly this reality. ECS delivers specialty-matched clinical review across more than 80 specialties, with the depth of experience and flexibility to support plans wherever the need arises. For a closer look at what that support looks like in practice, explore the case study below.

See how ECS helped one health plan answer a complex clinical question its own resources couldn’t resolve: Download Case Study.