How to Choose the Right Utilization Management Partner


Once your organization has decided to outsource utilization management, it’s time to find the right vendor to partner with. Like most modern services, there are an overwhelming number of options, so it’s important to know what to look for in a potential vendor. Above all else, you want to find a utilization management partner that puts members first and makes decisions with each individual’s best interests at heart.

At a minimum, the vendor should be accredited, but beyond that, there are certain qualities you should prioritize when searching for “the one.” If you’re ready to start your search, here are a few things to focus on while vetting different utilization management partners.

Data-Driven Clinical Decisions

Instead of relying on subjective opinions and guesswork, data-driven clinical decision-making uses evidence to make informed and verified decisions. It might seem obvious to incorporate data when discussing utilization management, but the reality is that the right data is not always available when you need it. Look for a partner that uses predictive analytics to make care decisions and forecast the medical needs of your member population. Another requirement should be that the partner incorporates the members’ medical history and current lifestyle into each care decision.

A reliable utilization management partner should collect and aggregate data on a regular basis. And not only should they store the data, but they should also be willing to share it with you. Data-driven decisions help all stakeholders—providers, payers, and members—have confidence in the chosen care pathway, especially in the new world of value-based care. Data can also help guarantee spend and cost savings. Having access to data can expedite clinical and financial decisions during the utilization management process.

Timely and Efficient

Delayed treatment or care can be harmful to members and costly to providers and payers. One question you should ask a potential vendor is the average amount of time it takes their review team to approve appropriate care. Ideally, this should be done as quickly as possible so that you can ensure that your members are receiving the right care at the right time.

Of course, speed is not the only goal. You’ll also want to ask about the process that the review committee uses; it should be efficient and evidence based. Also, the process should benefit your own organization. The right utilization management vendor should make the best clinical decisions for your members while relieving your staff of the administrative burden caused by utilization management tasks. Lastly, make sure the vendor has bandwidth and is the right fit for organization's size.

Transparent and Trustworthy

In any relationship, clear communication is key—and it shouldn’t be any different with your utilization management partner. To ensure that you can fully rely on your vendor, make sure they’re willing to be transparent about their process. Especially if the decision is a denial, the review committee should be willing to disclose details and have a discussion directly with the member’s provider. A trusted utilization management partnership is critical for collaborative payer-provider relationships.

As a trusted utilization management partner, TurningPoint is committed to applying the most appropriate healthcare services, reducing waste, and ensuring members receive optimal care. Above all, we strive to be a guiding partner throughout this process. Is our comprehensive utilization management program right for your organization? Let’s chat.

To learn more about TurningPoint’s suite of services, contact us today.

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