Cost Management Programs

Tufts Health Plan employs a robust set of medical and pharmacy cost management programs

These programs help ensure that our members receive care that is appropriate, and clinically proven to have better outcomes. This can save both costs and potentially unnecessary medical procedures or prescription drugs.

We also manage costs by making sure claims are accurate. These claims audit programs examine claims, hospital payments and provider billing to look for errors, overcharges, and inconsistencies.

Medical Cost Management

Cardiac Program 

Our health management programs address several different areas, including a cardiac program that reviews quality of care, patient safety and appropriate utilization for our members with heart disease. We also have a Center of Excellence at Lifespan Health in RI, which host the Dean Ornish Cardiac Rehab program, the only such center in New England.

Spine and Spine Pain Management

This program reduces medical cost with the use of evidence-based criteria to evaluate the medical necessity of spine related treatments and surgical procedures. When clinically appropriate, cases are redirected to an alternate, less invasive surgery or more conservative care.

High-Tech Imaging Program

This program reduces medical cost with the use of evidence-based criteria to evaluate the medical necessity of high cost imaging procedures. When medical necessity is not met the imaging procedure is denied, managing the medical trend of these highly utilized diagnostic tests.  Self-insured clients have seen ROIs of 2:1 or more (actual savings will vary by employer group).

Joint Surgery

This program reduces medical cost with the use of evidence-based criteria to evaluate the medical necessity of joint surgery. When clinically appropriate, cases are redirected to an alternate, less invasive surgery or more conservative care.   

For example, this program will access the increasing rate of total joint replacements across all age groups. 54% of the hip replacements for commercial members were performed on patients ages 40-60. These young patients will need future surgical revisions, which are expensive and less reliable. Also, the improper use of arthroscopic surgery is high, especially when it comes to arthritic joints. Clinical experts say that up to 80 percent of knee arthroscopies performed on patients over age 55 are unnecessary.  

But when surgeries are necessary, we have a Center of Excellence that we believe offers the most value and positive outcomes.

Pharmacy Cost Management

When it comes to drug coverage, our pharmacy management programs effectively help contain costs while managing quality, tailoring programs to meet an employer’s specific needs, with flexible options like a 3-tier copayment plan that encourages use of lower-cost generic and preferred brand medications. And a 4th tier to help manage high-cost specialty drugs.

We provide flexible programs and benefit plan options for employers.

You can also supercharge your tiered copayment coverage by adding our value-based pharmacy program that eliminates or reduces member cost sharing for specific medications related to the treatment of common chronic conditions.

Close Monitoring of Medication Compliance

We also have programs in place to actively monitor members with chronic conditions to promote optimal adherence, avoid complications and adverse interactions.

And Specialty Care Management teams that provide support with members who take costly specialty medications to help manage their condition and stay on track with their therapies.  

Active Management of Specialty Drugs

While only 5% of our membership is on the specialty drugs, their cost represents 40% of our pharmaceutical spend and it’s something we pay close attention to by:

  • Regularly evaluating spend and trend by specialty condition,
  • Management strategies based on clinical efficacy and lowest net cost, with consideration given to available rebates both through the PBM and directly from manufacturers
  • Monitoring of the specialty drug pipeline to assess its impact on our members and your employees based on the prevalence of those conditions.

Advanced Member Engagement Strategies

Our PBM has invested in digital capabilities with over 800+ digital experts and $300M over the last three years. As a result our members now have advanced digital tools to better manage their Rx needs, including:

  • Convenient, mobile-based refill management and refill alerts whenever they walk into a CVS store
  • Pick-up of specialty drugs at retail CVS stores
  • Information and support to search for drugs, understand their cost, explore lower-cost options and share that information with their doctors

Utilization Management

We help our members receive quality health care in an appropriate treatment setting, using up-to-date medical standards and medical necessity guidelines for making coverage decisions. Standards and guidelines are updated at least once per year, as new treatments, new uses for treatments, and new technologies are adopted as generally accepted professional practices.

We may check utilization of health care services before (prospective review), during (concurrent review), or after (retrospective review) members get them.

Pre-service Reviews

For services and prescriptions that require pre-authorization, we conduct pre-service reviews. If a member is hospitalized, we review all available information in order to facilitate the transition from hospital to home, or hospital to another health care environment. Reviews are also conducted post-service, to review prescriptions and other medical needs.

Clinical Coverage Decisions

For clinical coverage decisions regarding medical services, denials are made only by board-certified physicians. For clinical coverage decisions regarding medications, denials are made only by board-certified physicians or registered pharmacists.

Claims Audit Programs

Coordination of Benefits + Subrogation

We identify opportunities for additional coverage through COB, which has an ROI of 4:1, and subrogation, which recovers medical costs from a third party, such as workers’ compensation.

Code Review

This program monitors providers’ billing patterns to identify outliers. We perform outreach to these providers so they are aware of appropriate billing practices.

Pre-Payment Audit

We check the accuracy of itemized hospital bills for certain high-cost charges that need to be adjusted prior to payment. Other programs audit medical and specialty pharmacy claims on a pre-payment basis. We identify claims that meet specific criteria for frequency, utilization and cost. There are a dozen different medical services that receive pre-payment audit, from cardiology to orthopedics to urology. Our program to review pre-pay orthopedic claims has an ROI of 4:1.

Additional Audit Programs

Other audit programs include: 

  • Medical claims editing, which has an ROI of nearly 6:1
  • Post-payment claims and discount audits. Our post-payment review of pharmacy claims has an ROI of 4:1.
  • Provider audit recoveries
  • Overpayment recoveries



Answer a few quick questions (3 at most) and we'll direct you to the right place to get what you need.

Get a Quote