Toney Healthcare

Improving #MedicalLossRatio (MLR) has become one of the biggest challenges facing health plans today. As part of the Alerion Advisors family of companies, Toney Healthcare is helping health plans take a more comprehensive, action-based approach to improving MLR performance. Together with Alerion Advisors, Advent Advisory Group LLC, and Rebellis Group, we've developed an executive perspective and MLR Assessment designed to help health plans uncover opportunities beyond traditional cost management. If you're a health plan leader looking to learn how leading organizations are taking a comprehensive, action-based approach to improving MLR, we'd love to connect. Read the article👉 https://lnkd.in/ei3XYmk4

CMS' proposed 2027 Medicare Program #Audit Protocols reinforce the importance of strong #UtilizationManagement, timely clinical decision-making, and operational excellence. Audit readiness starts long before the audit notice arrives. Read the proposed protocols: https://lnkd.in/gy3m9RYW Learn how Toney Healthcare's Utilization Management solutions can help strengthen your clinical operations and audit readiness ▶️ https://lnkd.in/euE-Vexj

#AI is a powerful tool—but it shouldn't replace physician judgment. As this article illustrates, automation without appropriate clinical oversight can create delays, increase provider burden and negatively impact patient care. At Toney Healthcare, our physician review services provide the clinical expertise organizations need to make accurate, timely and defensible #utilizationmanagement decisions. Our board-certified physician reviewers deliver rapid, reliable turnaround times that help streamline the review process, reduce unnecessary delays, support providers and keep patient care moving forward. Technology works best when it's paired with physician expertise—combining efficiency with sound clinical judgment to improve outcomes for patients, providers, and health plans. Learn more ➡️ https://lnkd.in/euE-Vexj

#MA plans have days, not weeks, to act. 🔹 Notify CMS of intent to resubmit: June 22 🔹 Resubmit bids: June 29 🔹 Actuarial certification due: July 1 For plans receiving higher recalculated #QBP ratings, the opportunity isn't just additional revenue—it's how those dollars are invested. #CareManagement #UtilizationManagement #Quality #Stars The strongest organizations will use this opportunity to improve member outcomes while strengthening overall plan performance. How will your organization turn new funding into better outcomes? Contact us 👉 partners@toneyhealthcare.com

The HHS Office of Inspector General's latest reports on #MedicareAdvantage denials are a reminder that #utilizationmanagement decisions remain under increasing scrutiny. Health plans need experienced physician reviewers, strong clinical oversight and defensible medical necessity determinations. Toney Healthcare provides Physician Review Services, Interim Medical Directors and Utilization Management support to help plans maintain compliance, improve consistency and support better member outcomes. Whether you need surge capacity, interim leadership or ongoing UM support, we serve as an extension of your team. Learn more 👉 https://lnkd.in/egRTy4Mg Contact us 👉 partners@toneyhealthcare.com

Now #hiring! We are looking for an experienced UM Supervisor to lead, mentor and make an impact—all while working remotely. ✅ 5+ years UM experience ✅ 2+ years leadership experience ✅ Active RN license ✅ InterQual/MCG knowledge Apply today 👉🏼https://lnkd.in/eh_DuFQi

By now, many #MedicareAdvantage leaders have read about the Clover Health ruling and its potential implications for #StarRatings. The bigger challenge? Navigating regulatory change, quality performance, member outcomes and increasing #MLR pressure—all while maintaining operational excellence. When requirements change, operations must adapt. 🔹 Clinical Operations 🔹 Quality Performance 🔹 Regulatory Readiness 🔹 Member Outcomes At Toney Healthcare, we help health plans navigate complexity with confidence. Learn more:

As #CMS accelerates momentum toward electronic #priorauthorization and #interoperability requirements, health plans are being challenged to modernize workflows while reducing provider abrasion and administrative burden. That’s where Toney Healthcare and our Physician Review Services come in. Our physicians serve as an extension of your team — supporting #utilizationmanagement, clinical review operations, provider engagement and evolving prior authorization strategies with scalable expertise and operational insight. As the industry moves toward 2027 readiness, organizations need partners that can help bridge compliance, clinical operations and transformation. Learn more ▶️ https://lnkd.in/gSRAfkq2 👇Read more https://lnkd.in/ghHFqd6f

Looking forward to attending the California Association of Health Plans (CAHP) seminar focused on Artificial Intelligence in Healthcare. As health plans continue navigating growing authorization volumes, interoperability requirements, evolving #AI-enabled workflows and increasing pressure for defensible clinical decision-making, operational readiness has never been more important. Toney Healthcare is proud to support plans with scalable expertise across: ✔️ Utilization Management ✔️ Care Management & Care Coordination ✔️ Clinical Operations ✔️ Physician & Nurse Reviewer Support ✔️ Compliance & Operational Readiness Excited to connect with our partners to discuss how organizations can balance innovation, compliance and member experience in an evolving landscape.