Not finding out when a participant is hospitalized until it’s too late.
Admissions defaulting to inpatient with no review.
UM policies that exist on paper but not in daily practice.
These are the clearest signs that a PACE program is playing defense on utilization management instead of getting ahead of it.
If you recognized your program in any of those signs, the natural next question is: how do I start building a more proactive utilization management approach?
Three PACE programs of very different sizes answered that question in our recent webinar, Stop playing defense: Three PACE programs on managing utilization before it manages you. And their answers reveal three replicable steps.
Mountain Empire PACE, a single-site, rural program; One Senior Care, a multi-state entity with several small to medium PACE programs; and Element Care, a large multi-center program, all adopted a more proactive approach to utilization management with IntusCare’s PRISM services.
Here’s how.
1. Start with inpatient admissions, then expand
Every program on the panel followed roughly the same sequence to better manage utilization: address inpatient hospital admissions first (typically the biggest cost driver), then prior authorization for pre-approved procedures, then skilled nursing facility authorizations.
IntusCare Chief Population Health Officer, Laura Ferrara described the utilization management as a service (UMaaS) work she does with PACE programs as a phased approach. “We start our work on the admission, the hospital admission side. And then our next phase is typically prior authorization for pre-approved procedures,” things like heart caths, stents, and joint replacements. “And then… we also do skilled nursing facility authorizations.”
Starting narrowly isn’t just easier. It’s what makes rollout manageable for programs, especially those with more than one location. One Senior Care, which had four centers when it began working with IntusCare, piloted the entire process at a single center before expanding.
“We started with one particular center,” Ferrara said, “in order to get the policies, procedures, everything ironed out, and then we rolled it out to the rest of the organization.”
So start with a small, manageable scope. Then scale up, but only once the policies and training behind it are ready to scale too.
2. Build a policy and training before you need it
For One Senior Care, the first 90 days weren’t spent managing cases. They were spent building the foundation to manage cases well.
“The first 90 days was really about identifying where we are at, identifying what Intus can bring to the table, and then identifying those gaps so that we could really get a structured plan going forward,” said Chief Nursing Officer Betty Mikovich.
That meant a significant investment in writing and revising policies and procedures, and in joint education. “We were able to create, with IntusCare, a collaborative meeting with each one of our hospital systems,” six or seven systems in total, resulting in what Mikovich called “an absolutely fantastic educational program.”
That same investment in training paid off on the clinical side at Element Care. Chief Medical Officer Dr. Anthony Zizza credited the depth of preparation his physicians received before their first peer-to-peer conversations with hospital UM teams: “I was so impressed with the training from Intus… a lot of training, a lot of information, a lot of communication, so that when they were ready to go, they felt empowered.”
That framing mattered for how his team experienced the change: “UM is not something done to them, it’s something that they partner with.”
The practical takeaway for programs: bring finance, clinical leadership, and providers to the table early, not after the fact. Mikovich noted that having “all of our key players” in the room from the start, including finance, was what let One Senior Care understand the full organizational impact before rollout.
3. Don’t wait for a census threshold. Start day one.
When asked directly whether a new program should wait for a certain census before implementing UM, Mikovich didn’t hesitate:
“My opinion is day one. Have that part of your integration process from the very get-go… as you’re opening up the de novo plan, make sure that IntusCare is involved in that ahead of time.”
Ferrara’s take: it’s not about when you’re ready. It’s about how much risk you’re willing to carry in the meantime. “How many bad claims do you [want to] pay before you decide to do it?” she said. “There [are] going to be claims that are an inpatient level that are submitted that you should not have to pay at that level… It’s like a seatbelt. You don’t want to use it, it’s not comfortable, but when you need it, you have it and it works really well.”
For larger, multi-site programs, day one still means starting immediately. It just doesn’t mean going all-in everywhere at once. Dr. Zizza described starting physician involvement with a small medical leadership group before expanding to the full physician team.
Ferrara echoed the same scaled approach, but by opportunity size. Start with your biggest opportunity (typically inpatient), then expand into SNF and prior authorization, one center or region at a time.
The payoff of proactive utilization management in PACE
Across all three programs, the results of proactive utilization management looked different in scale but similar in approach.
Mountain Empire PACE gained a negotiating position it didn’t have before. “We’re not feeling like we’re being taken advantage of,” said PACE Director Ruby Kennedy, whose program once had no choice but to absorb whatever costs of care the local health system decided.
That same shift showed up financially. For a program Kennedy’s size, a single bad week of claims payments used to be existential: “It wasn’t that long ago that a weekly check run could absolutely devastate us.” Now, high-cost hospitalizations still happen, but “there’s actually a justified reason for it.”
And at One Senior Care, the savings haven’t just stayed on a spreadsheet. “We’ve been able to bring [those] dollars back into our organization to provide additional services to our participants,” Mikovich said, funding growth into underserved rural areas and new services for existing participants.
Dr. Zizza described a similar reinvestment loop at Element Care, tying the financial upside directly to team culture: “If we do well, the team is going to do well, and the patients are going to do well, because we’re keeping them at home.”
The numbers back up the story. Between August 2025 and June 2026, Element Care saved a median of $112,222 a month and $1.48M in total. And that’s just the start. Dr. Zizza expects that number to keep climbing, since the program has so far focused mainly on inpatient admissions and is only beginning to scale into SNF and prior authorization. “If we came back in a year, we would probably see this number quite a bit higher.”
One Senior Care, saved $763K over the same period. And Mountain Empire PACE saw an estimated $44,100 median savings per month, or $529K in total, pending final claims data.
The shift shows up in the claims data too. Typically, programs partnering with IntusCare on UMaaS see roughly 27% of hospital authorization requests move from inpatient to observation once evidence-based criteria are applied consistently — claims that would otherwise have been billed and paid at a higher level of care than the participant needed.
Ready to reimagine your utilization management approach?
Watch the full webinar to hear directly from leaders at Mountain Empire PACE, One Senior Care, and Element Care. Or talk with our team to see how much proactive utilization management with IntusCare could help save your program.
