Prior Auth dashboard
Executive view of pre-service workload, conversion risk, and reviewer focus areas.
Search provider, member, pathway, claim
Queued requests
218
Today across 5 pathways
High-risk encounters
42
Provider or member context mismatch
Auto-approval rate
61%
Down 4 points week over week
Avg manual turnaround
6.4h
For pended requests
Pre-service pressure points
Where management should tighten review coverage
This week
Analyst staffing snapshot
Distribution of manual review queue
8 active reviewers
Need clinical docs
31 requests aging beyond 4 hours
Provider outlier overlap
18 pended cases tied to 3 ordering groups
Conservative care gap
26 requests missing pathway prerequisite evidence
Top providers driving pends
Management review candidates
Region East
| Provider | Requests | Pend rate | Main issue |
|---|---|---|---|
| Atlantic Spine Center | 41 | 48% | Early advanced imaging |
| Suncoast Ortho | 28 | 32% | Repeat DX reuse |
| Coastal Rehab | 19 | 24% | Referral closure gaps |
Management actions
Suggested intervention levers
Priority
1. Expand second-look review
Apply to lumbar MRI requests from top two outlier providers.
2. Rebalance workload
Shift two reviewers to documentation chase queue during peak hours.
3. Update provider education
Target providers with repeated conservative-care bypass patterns.
Open provider cases
37
Across active SIU regions
Paid exposure
$8.4M
Trailing 12 months under review
Recent submissions
1,126
Not yet surfaced in legacy workflow
Referral-ready cases
9
Network pattern evidence assembled
Exposure by suspicious pattern
Management allocation across investigation themes
Paid + submitted
Case operations
Current bottlenecks in investigation flow
This month
3 cases awaiting data pull
Linked affiliate roster not yet attached
2 cases nearing referral
Need updated unpaid submission counts
Large office visit cluster
Most volume concentrated in low-cost E/M services
Highest exposure providers
Case-level ranking for leadership review
Top 5
| Provider cluster | Claims | Exposure | Status |
|---|---|---|---|
| Harbor Pain Group | 14,382 | $2.8M | Escalate |
| Sunset Rehab Network | 9,114 | $1.7M | Monitor |
| Metro Spine Affiliates | 7,886 | $1.3M | Build case |
Leadership guidance
Where to focus SIU capacity
Recommended
Prioritize office visit clusters
They produce the broadest claim footprint even when dollar value per claim is low.
Keep unpaid claims visible
Recent submissions materially change referral timing and intervention choices.
Bundle affiliate evidence earlier
Shared addresses and rendering loops strengthen post-payment case posture.
Monitored providers
412
Across active care pathways
Flagged pathways
63
Above deviation threshold
Peer cost drift
+18%
Across highest-variance cohorts
Manager review queue
21
Provider-pathway combinations
Deviation clustered by pathway
Variation is concentrated, not uniform
Orthopedic
GI
Cardio
| Pathway | Providers flagged | Main drift | Priority |
|---|---|---|---|
| Low back pain | 18 | MRI before conservative care | High |
| Cervical radiculopathy | 9 | Early specialist handoff | Moderate |
| Knee osteoarthritis | 4 | Stable sequencing | Low |
| Shoulder pain | 3 | Minor therapy lag | Watch |
Review focus
Management triage
30 days
Low back pain
Highest sequencing deviation and spend impact
Three-provider referral loop
Repeated after early imaging events
Episode revisit spike
Higher return visits after non-standard sequence
Variance intensity map
Visual concentration by pathway
Market East
Manager interventions
Actions that improve signal quality
Priority
Refine pathway definitions
Reduce false positives by tightening start and end episode criteria.
Assign pathway owners
Make one reviewer accountable for each high-variance pathway family.
Escalate provider education
Concentrate on pathways where drift repeats over time.
Current request
PA-48271
MRI lumbar spine · CPT 72148
Member related claims
4
Last 180 days
Provider signal
87
High pathway deviation
Suggested action
Pend
Request conservative-care proof
Encounter context
Single request with pathway-linked timeline
Low back pain
Surfaced because:
Provider escalated to advanced imaging before conservative therapy in 31% of similar episodes.
Today
Proposed lumbar MRI without contrast
DX M54.50 · ordering provider Atlantic Spine Center
Pending
18 days ago
Office visit + pain assessment
No PT claim found after evaluation
Gap
73 days ago
PT referral not utilized
Referral created, no paid therapy claims on file
Missed step
Analyst guidance
Fast review prompts
Decision support
Check docs for failed conservative care
No visible PT utilization in prior episode
Review ordering pattern
Provider has repeated MRI-first behavior on same pathway
Verify episode restart
Same DX reused across prior claims
Drill down: member and provider evidence +
Member prior claims
| Office visits | 9 |
| Injections | 4 |
| Physical therapy | 0 |
| Imaging | 3 |
Provider pathway signals
92nd percentile MRI-before-PT
Compared with orthopedic peers
Shared billing address
Matches previously flagged rendering entity
Recommended next step:
Pend request and ask for conservative-treatment documentation before approval.
Provider cluster
14,382
Claims linked to case
Paid exposure
$2.8M
Trailing 12 months
Recent submissions
186
Not in legacy queue
Case posture
Escalate
Office visit churn + affiliate overlap
Linked suspicious claims
Paid and submitted claims in one investigative queue
All linked claims
Office visits
Imaging
| Claim | Service | Status | Signal | Amount |
|---|---|---|---|---|
| CLM-992184
04/11/26
|
99213 office visit | Paid | High repeat frequency in 14-day window | $148 |
| CLM-992201
04/12/26
|
20552 trigger-point injection | Submitted | Follows suspect office visit cluster | $366 |
| CLM-991433
04/03/26
|
99214 office visit | Review | Same-day overlap with affiliate location | $176 |
Investigator filters
Narrow very large claim volumes quickly
Case filters
Status
Paid + submitted
Service family
E/M, imaging, injections
Affiliate match
On
Pathway anomaly
Above 0.70
Drill down: case evidence and network links +
Suspicion drivers
Network links
3 shared billing addresses
Connected to 5 NPIs under active review
2 rendering affiliates
Volume surges after referral handoffs
2,904 affected members
Across paid and submitted claims
Investigator note:
Keep low-cost office visits visible because they represent the broadest suspicious footprint.
Provider
NPI 1940283
Atlantic Spine Center
Flagged pathways
3
Of 11 monitored pathways
Peer variance
+41%
Imaging-heavy low-back path
Primary focus
Lumbar pain
Highest sequence drift
Care pathway deviation
Compare this provider with peers
Low back pain
Knee OA
Radiculopathy
| Pathway | Typical peer sequence | This provider | Variance |
|---|---|---|---|
| Low back pain | Visit → PT → MRI → injection | Visit → MRI → injection → PT | High |
| Knee OA | Visit → x-ray → PT → injection | Visit → x-ray → PT → injection | Stable |
| Cervical radic. | Visit → med → PT → MRI | Visit → MRI → follow-up | Moderate |
Analyst focus
Most useful next review steps
Actionable
Audit MRI-first episodes
Especially those followed by injections
Check repeat specialist loop
Three specialists recur after imaging
Review revisit rate
Higher after non-standard sequencing
Drill down: peer position and episode detail +
Peer position
Imaging use: 94th percentile
Before conservative care in low-back episodes
Episode cost: +28%
Above market-adjusted peer average
Pathway adherence: 6 / 11
Currently inside expected ranges
Example episode sequence
Day 1
Office visit
Low-back diagnosis assigned
Start
Day 7
MRI ordered
Before PT or medication trial
Drift
Day 19
Injection billed
Episode cost accelerates early
Review
Suggested pathway review:
Prioritize low-back episodes where imaging and injection occur before any conservative step appears.