CASE STUDY
USFHP and Toney Healthcare: Partners in Utilization Management
Elevating Care Experience through Collaboration & Engagement
The Problem
St. Vincent Catholic Medical Centers Uniformed Services Family Health Plan (USFHP) supports approximately 14,000 beneficiaries as part of the Department of Defense-sponsored TRICARE Prime program. When Dr. Roberta McNeill joined USFHP as Chief Medical Officer in late 2021, she faced a significant challenge—the plan had just received a sudden termination notice from an outsourced vendor who managed medical necessity determinations for nurses and physicians. USFHP needed an immediate and effective solution.
The Solution
In early 2022, USFHP made the decision to partner with Toney Healthcare to address their urgent medical review needs. Toney Healthcare delivered a comprehensive utilization review team within 30 days, ensuring seamless transition and uninterrupted service delivery.
During the transition, additional issues were uncovered that caused USFHP to also terminate all remaining services with the previous vendor, including intake, call center, and technology. Toney Healthcare once again stepped in, taking on these additional services and leveraging its comprehensive utilization management expertise to support a technology transition from the previous vendor’s proprietary platform. With Toney Healthcare’s support, the transition for all services and technology was complete within four months of Dr. McNeill’s start date.
This successful partnership expanded in November 2023 to encompass an entire suite of utilization management services spanning customer service, intake, case setup, clinical review, physician review, appeals and fulfillment to continue driving efficiency, quality and clinical consistency.
Operational Results
Compliance cleanup of over 250 non-compliant cases left by the previous vendor, completed in 2 days
Improved turnaround times to 98% – 99% in compliance, with timely determinations even during challenging periods
Boosted efficiency across processes and workflows
Integrated team approach with Toney team as a seamless extension of USFHP, working in USFHP systems
Enhanced member experience with fast turnaround times and quality support
The Team—Integrated Partnership
Toney Healthcare deployed a comprehensive team of experienced clinical and non-clinical staff and leaders to deliver and manage all USFHP medical necessity review operations, fully integrated with USFHP’s team. With this partnership model, called an Insource Partnership, Toney Healthcare works as a dedicated extension of USFHP, with full visibility and responsibility for key performance metrics without the burden of delegation oversight and without the hiring, performance management, or training requirements of building an in-house team. The partnership was quickly and smoothly expanded to include intake and call center services.
Because Toney resources work in USFHP’s systems, work is bidirectional and communication is real-time and seamless, with close collaboration and mutual learning that makes both teams more effective. All actions are transparent so stakeholders are aligned and informed.
“Toney Healthcare is more than a vendor—they are an integrated part of our plan’s team. They’re always ‘on it,’ and do a great job making sure we don’t feel any bumps during the transition across Toney and USFHP resources. I can’t express how important that seamless integration is.”
- Dr. Roberta McNeill, CMO, US Family Health Plan
Strategic Advisory
Joint strategy development and operational planning
Infrastructure building with support for technology transition and optimization
Process improvement focusing on workflow automation, compliance, efficiency, and member experience
Expertise to adapt to changing business and regulatory requirements
Leadership training for health plan and TRICARE capabilities
The Transition—Process and Tech Optimization
Toney Healthcare approaches a partnership with a focus on continual improvement in addition to immediate operational needs—finding ways to enhance efficiencies, shorten turnaround times, and reduce errors. The Toney team applied its deep clinical expertise and knowledge of regulatory requirements to support the technology transition, working with the new vendor to configure the platform to support USFHP’s utilization management workflows and business requirements and to test the implementation to ensure everything worked as expected. This approach helped USFHP build the necessary infrastructure for sustained success.
As part of the transition, Toney Healthcare eliminated a large backlog—more than 250 cases from the previous vendor that were not meeting TRICARE requirements. The Toney team responded quickly, bringing all cases back into compliance within two days. Their efforts not only addressed the immediate backlog, but also established a process to manage incoming cases effectively, preventing further compliance issues and ensuring a timely response to member needs.
“The Toney team really stepped up when we needed them to smooth the transition and make sure the technology aligned with our processes and standards. It required a lot of flexibility, but we were all in it together. They went above and beyond what was required.”
- Dr. McNeill, USFHP
Toney Healthcare serves as USFHP’s external face to providers and members, representing USFHP on the front lines of utilization management. Intake comes first through the Toney team, who ensures that every service is medically necessary and that care is directed to USFHP’s network when possible. The Toney team participates in biweekly rounds with USFHP to keep everything on track and ensure no members fall through the cracks.
USFHP’s Face to the Customer
“Even though we are different organizations, we work together as one—Toney acts as USFHP to anybody outside our organization. This type of trust in a partnership—a true collaboration focused on open communication and mutual improvement—is unique among our vendors.”
- Dr. McNeill, USFHP
Strategic Partnership for the Future
Toney Healthcare’s partnership with USFHP extends beyond immediate operational needs. The collaboration also focuses on long-term strategic planning to help USFHP drive operational efficiency, compliance, and strategic growth and lay the foundation for long-term success and member satisfaction.
“Toney Healthcare is excellent at pivoting to address unanticipated issues—this flexibility and can-do approach is extremely valuable for our membership and our staff,” said Dr. McNeill. “They collaborate with an eye towards immediate success and long-term results. Other vendors aren’t that engaged.”
Ready to learn more?
Toney Healthcare’s team of experts is ready to collaborate with your health plan to support your care and utilization management needs across medical and behavioral health and all business lines