Managed Care
Comprehensive Cost Containment and Quality Assurance
TPS’s managed care program delivers integrated cost containment and quality assurance solutions designed specifically for municipalities, counties, school districts, hospitals, junior colleges, and other political subdivisions across Texas. Our comprehensive approach ensures your organization receives the highest quality healthcare services while maintaining fiscal responsibility and operational efficiency.
Our Complete Range of Managed Care Services
Peer Review
Our clinical professionals conduct thorough peer reviews to evaluate the medical necessity and appropriateness of care provided to your members. This physician-led process ensures treatment decisions meet established clinical standards and guidelines, helping identify quality improvement opportunities while maintaining the highest standards of care delivery.
Utilization Review (UR)
We implement a three-tiered utilization review system that evaluates the efficiency, appropriateness, and medical necessity of all healthcare services:
Prospective Review
- Pre-service assessment to determine medical necessity before treatment begins
- Precertification for both inpatient and outpatient services
- Prior authorization using nationally recognized clinical criteria
- Prevention of unnecessary procedures and inappropriate care settings
Concurrent Review
- Real-time monitoring during active treatment episodes
- Length of stay management and optimization
- Discharge planning coordination
- Care transition management to appropriate levels of service
Retrospective Review
- Post-service evaluation of treatment appropriateness and outcomes
- Claims accuracy verification and coding review
- Pattern analysis to identify opportunities for improved care delivery
- Quality assurance and compliance monitoring
Preauthorization/Precertification
Our streamlined preauthorization process ensures coverage verification before services are rendered, using evidence-based medical necessity screening tools and nationally accepted admission criteria. This proactive approach minimizes claim denials, reduces administrative burden, and guarantees appropriate care delivery from the outset.
Medical Bill Review
Our experienced billing professionals conduct comprehensive reviews of all medical claims to ensure:
- Accurate procedure and diagnostic coding
- Compliance with benefit plan guidelines and coverage terms
- Appropriate reimbursement according to contracted rates
- Detection and prevention of billing errors and fraudulent claims
- Expedited processing and resolution of payment issues
Pharmacy Benefit Management (PBM)
Our pharmacy benefit management services optimize medication costs while ensuring clinical appropriateness through:
- Comprehensive formulary management and maintenance
- Prior authorization protocols for specialty and high-cost medications
- Step therapy programs promoting cost-effective treatment pathways
- Generic substitution policies and therapeutic alternatives
- Drug utilization review and safety monitoring
- Pharmacy network management and contract negotiations
Case Management
Our licensed case managers specialize in coordinating care for high-risk members and complex medical situations. Services include:
- Care coordination across multiple providers and specialties
- Transition management between care settings
- Resource identification and utilization optimization
- Member advocacy and support services
- Chronic disease management programs
- Rehabilitation and recovery planning
- Cost-effective alternative care arrangements
Dedicated Account Management
Designated Bill Processing Professionals
Every TPS member organization receives dedicated bill processing professionals who provide:
- Personalized Service: Deep understanding of your specific benefit plans and organizational needs
- Consistent Communication: Single point of contact for all managed care inquiries and issues
- Streamlined Processing: Expedited handling of authorizations, claims, and appeals
- Proactive Management: Ongoing monitoring and optimization of your managed care program
- Expert Support: Immediate access to experienced professionals who know your account
The TPS Advantage
Integrated Approach: Our comprehensive managed care services work together seamlessly to create a cohesive cost containment and quality assurance system that identifies patterns, prevents unnecessary utilization, and improves health outcomes.
Evidence-Based Standards: All utilization review decisions are based on nationally recognized clinical guidelines and medical necessity criteria, ensuring consistent, appropriate care determinations.
Technology-Driven Efficiency: Advanced systems and automated workflows streamline processes, reduce administrative burden, and provide real-time reporting and analytics.
Regulatory Compliance: Full compliance with all federal and state regulations, including CMS requirements, HIPAA privacy standards, and Texas insurance guidelines.
Cost Transparency: Detailed reporting and analytics provide clear visibility into utilization patterns, cost trends, and program performance metrics.
Measurable Results
Our managed care program delivers quantifiable benefits including:
- Reduced healthcare costs through elimination of unnecessary services
- Decreased claim denial rates through proactive authorization management
- Improved member satisfaction through coordinated, appropriate care
- Enhanced provider relationships through streamlined processes
- Better health outcomes through quality-focused care management
Getting Started
Contact TPS today to learn how our managed care services can help your organization achieve optimal healthcare outcomes while maintaining fiscal responsibility. Our team of experts will work with you to design a customized managed care solution that meets your specific needs and budget requirements.
