Going Beyond Medical Policy Digitalization to Enable Automation at Scale   

In the last segment of this three‑part series we sit down with Lydia Turner, Senior Manager of Strategy & Health Industries at PwC, to take a deeper look at the foundation of every utilization management (UM) decision: medical policy. Lydia explains why medical policy codification is the “engine” behind both automation and clinical accuracy and how outdated, ambiguous, or unstructured policies can undermine even the most advanced UM strategies.  

She also breaks down what health plans must do to ensure policies are accurate, current, machine-readable, and evidence based, so they can be safely used by automation and AI. She also discusses the governance structures health plans need to create long-term consistency, shared accountability, and sustainable ROI.  

Key Insights from the Conversation 

Medical policy is the decision logic behind every UM outcome 

Medical policy isn’t just a foundation, it is the engine behind every manual, automated, and AI‑supported determination in utilization management. Lydia makes it clear that automation can only be as good as the policy it’s built on. 

Outdated, ambiguous, or inconsistently applied policies don’t slow automation down—they cause automation to accelerate the problem, leading to:

• Decisions that don’t align with current clinical evidence 

• Higher overturn and appeal rates 

• Increased provider and member abrasion 

• Greater audit and compliance risk 

Without strong medical policy maintenance, plans may move faster or cheaper, but not better. 

Digitization alone doesn’t enable automation  

CMS guidance may require digitized medical policy, but Lydia emphasizes that digitized does not equal automation‑ready. AI and automation deliver value only when teams structure, standardize, and codify policies so technology can interpret and apply them consistently. Best‑practice policy design requires: 

• Clear separation of clinical intent and operational rules 

• Standardized, structured formats that technology can consume 

• Language that can be translated into logical provider questions and workflows 

A policy isn’t automation‑ready if teams can’t operationalize it into clear attestation questions providers can answer.

Policies must be written for clinicians and machines 

Historically, medical policies were written solely for clinical review. In an AI‑enabled UM environment, Lydia notes that policies must serve a dual audience: clinicians and machines. 

That shift means policies must: 

• Preserve clinical nuance and evidence‑based intent 

• Clearly define how teams should operationalize decisions

• Enable AI to interpret criteria accurately and consistently 

• Support automation without introducing ambiguity 

This balance ensures that AI augments decision‑making rather than misinterpreting or oversimplifying it. 

Traceability, version control, and review cadence are non‑negotiable 

Strong policy governance goes beyond content. Lydia highlights that traceability and version control are critical to consistency, auditability, and trust. 

Effective policy governance includes: 

• Clear linkage to source evidence and clinical rationale 

• Full audit history of policy changes over time 

• Version control to explain differences across determinations 

• A defined, repeatable review cadence based on time or emerging evidence 

Without this rigor, well‑intentioned changes introduce unexplained variability.

Governance enables speed, quality, and ROI to coexist 

Policy readiness and automation success ultimately depend on governance. Lydia stresses that long‑term UM transformation requires consistent shared ownership across disciplines, not episodic collaboration. 

Successful governance models bring together: 

• Clinicians 

• UM operations 

• Technology teams 

• Analytics and medical economics 

• Compliance stakeholders 

With shared accountability, these teams create a continuous feedback loop, evaluating performance, identifying improvement opportunities, and refining policy and workflows over time. 

Absent cross‑functional governance, plans must choose between speed, accuracy, compliance, experience, and ROI.

Ready to put these insights into action? 

Explore the Insourcing Utilization Management Blueprint to see how leading health plans are reclaiming control of medical policy, decision logic, and UM performance, while improving speed, accuracy, and provider trust. 

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