End-to-End
Utilization Management
Intake and Nurse Review.
Physician Review.
Appeals & Grievances.
If you are focused on expanding into a new geography or line of business, improving performance, or simply closing resource gaps, Toney Healthcare can help. We provide comprehensive, end-to-end utilization management (UM) solutions for managed care organizations. Available as complete teams or individual resources, our utilization management experts can help you stay compliant, reduce friction, improve operational and quality performance, and create a better experience for members and providers.
Our highly experienced, entirely onshore team supports all aspects of medical and behavioral health utilization management—including initial clinical review, physician review and appeals and grievances— and are all appropriately licensed with relevant health plan experience.
Because we operate on your platform, deploymentis quick, activities and outcomes are transparent, and all data stays in your control
Comprehensive Utilization Management Operations
Whether you seek support across your entire utilization management program or only for part of the continuum, Toney Healthcare’s services always include:
Expertise in all facets of physical health, behavioral health, ancillary services and pharmacy UM across all lines of business
Experience providing UM services to over 50 health plans and other risk-bearing entities
Support for inpatient, outpatient, partial hospitalization, long-term, durable medical equipment (DME) and more
Standard and expedited reviews
Vast medical necessity criteria expertise, including NCD/LCD, MCG, InterQual and more
Fast turnaround times to ensure compliance with plan and regulatory requirements
Fluency in national and regional requirements, benchmarks, accreditation standards and best practices
Expertise in medical policy and prior authorization list development
Service delivery via remote access since our founding
INITIAL CLINICAL (NURSE) REVIEW
Our intake and clinical teams bring efficiency, compliance and utilization management best practices to our clients. We can quickly deploy individuals and teams for all lines of business to serve any geographic area. We provide:
Expertise in preauthorization, concurrent review and retrospective review
Post-acute and transitions of care support
Clinical and non-clinical operators with diversity of experience across organizations, geographies, lines of business, criteria sets, and platform
Clinical leaders with extensive health plan UM experience
Frontline staff all with prior health plan experience Robust recruiting process with vetting from senior clinical leaders
Appropriately licensed RNs, LPNs and behavioral health clinicians by state and/or compact license
Utilization management letter fulfillment
PHYSICIAN REVIEW
Toney Healthcare offers an extensive panel of appropriately licensed physician reviewers that can be deployed quickly so that you can be responsive to your membership, meet turnaround times, and avoid compliance penalties.
Medical, behavioral, and specialty reviews for all major specialties
Clinical criteria and lines-of-business expertise Fast turnaround times to ensure compliance with plan and regulatory requirements
Full- and part-time, including support for gaps in coverage hours
After-hours and weekend support
Support for peer-to-peer consults, committees and other UM requirements
Appropriately licensed physicians available across all states
Advisory services to optimize processes, automate clinical decision-making, and ensure the right cases are elevated for physician review
APPEALS & GRIEVANCES
Our experts can support your appeals and grievances processes to help you manage risk and improve quality and compliance, ultimately increasing member satisfaction and trust.
Intake coordinators, nurse specialists, and physician reviewers, available as individuals or complete teams
Medical and behavioral health support
Appeals triage and case management
Clinical documentation and medical necessity review
Deep expertise with national and regional best practices and regulatory guidelines
Advisory services to optimize processes and ensure compliance
Toney Healthcare’s team of experts is ready to help you address your utilization, care and behavioral health resource needs with plug-and-play health management services and expertise so you get the help you need, fast—and without HR headaches.