As the healthcare industry continues to shift from a fee-for-service to value-based care approach, focusing on the quality of care rather than the quantity of care delivered is especially important. The process of utilization management is crucial in determining the optimal care plan for each patient.
Of course, the tricky part is delivering the highest quality of care, at the right time and place, while concurrently keeping costs at bay. Unfortunately, there isn’t a one-size-fits-all approach to evaluating appropriate care services; and that’s why having a utilization management partner primarily focused on safety and quality is so important to help advance value-based care. While utilization management is complex, there are a few key elements at the core of the process.
Comprehensive Clinical Guidance
At the most basic level, a utilization management program should be clinically sound, but providers and payers shouldn’t settle when it comes to clinical criteria. The primary component of utilization management is a set of evidence-based clinical guidelines, developed by an experienced and diverse medical team. The more comprehensive the clinical guidelines are, the better the chances that the patient will be connected to the optimal treatment.
At TurningPoint, our team of world-renowned clinicians design and implement our clinical guidelines firsthand. Our market-leading clinical proficiency adds a layer of confidence to the decisions made for patient care and treatment. When a provider talks with our team, they will always speak with a doctor within their subspecialty who aims to be as collaborative and supportive as possible. Ultimately, our goal is to be a safety net for health plans, ensuring that the most appropriate care decisions are made at every step, every time.
Cost Savings & Predictable Spend
Cost of care continues to be a major problem throughout the U.S. healthcare system. Utilization management can help to ensure that spending is appropriate and efficacious. By directing providers to deliver the most beneficial and appropriate care, all parties benefit from lower medical expenses, increased efficiency, and better outcomes.
In alignment with value-based care, medical treatments that are optimal for patients result in better outcomes and downstream cost avoidance (i.e., fewer ER visits, lower surgical revision rates, lower Skilled Nursing Facility (SNF) utilization, etc.).
Our utilization management solution sets health plans up for financial success. Since we are completely confident in the safety and quality of our program, we engage in risk arrangements that guarantee cost savings and provide financial predictability.
Collaborative Provider Relationship
TurningPoint’s solution moves beyond traditional denial-based programs. We believe all parties—payers, providers, and patients—can benefit from a synergistic utilization management program.
At TurningPoint, we use utilization management to collaborate directly with the provider. Our well-trained clinical staff use a patient-first approach to make care decisions and cooperate with providers, as needed. Additionally, we offer proactive education, network support, and analytics for individual providers and practices.
We recognize that traditional utilization management can be cumbersome and a source of divergence between providers and payers. However, it’s a critical and effective step in a patient’s health journey. Our main goal as your utilization management partner is to improve health outcomes.
To learn more about TurningPoint’s suite of services, contact us today.