Cardiac, MSK utilization management program helps control high-cost care
Blue Cross and Blue Shield of Kansas City (Blue KC) is supporting your organization with help managing healthcare costs while maintaining access to high-quality care. In collaboration with TurningPoint Healthcare Solutions, Blue KC is enhancing the way we approach cardiac and musculoskeletal (MSK) services — drawing on our partner’s expertise to strengthen utilization management (UM), prioritize payment integrity, and foster meaningful provider engagement.
Why this program matters
On average, cardiac and MSK procedures are among the most expensive and commonly performed. Without proper oversight, these procedures can lead to the potential for:
- Unnecessary spending due to inappropriate settings or coding practices
- Clinically questionable care that may not align with best practices
- Limited transparency into provider behavior and outcomes
Our cardiac and MSK UM program, in partnership with TurningPoint, is designed to address these challenges, offering a clinically rigorous and cost-effective-minded solution that’s already delivering results for our fully insured clients. Now, self-funded clients can opt in to the same program.
Four ways our cardiac and MSK UM program delivers value
- Site of care redirection – TurningPoint works in collaboration with providers to shift procedures from inpatient settings to outpatient or ambulatory surgical centers (ASCs) when clinically appropriate, resulting in opportunities for meaningful savings, particularly for MSK procedures.
- Coding review edits – TurningPoint aims to ensure only appropriate codes are approved, helping prevent overbilling and inflated claims.
- Clinically inappropriate care prevented – The program aims to identify and prevent procedures that aren’t the best clinical option, guiding providers toward more appropriate alternatives. This not only improves care quality but also reduces unnecessary costs.
- Unnecessary codes identified and withdrawn – TurningPoint helps provide additional savings and improved care alignment by identifying codes during their review that are not clinically necessary.
What it means for you
TurningPoint reviews a broader set of procedures than standard prior authorization programs, offering deeper oversight and more opportunities to reduce waste.
For self-funded employers, this cardiac and MSK UM program in partnership with TurningPoint is a strategic solution that helps you spend smarter, helps employees receive the right care at the right time, and offers a strategic way to manage high-cost procedures with confidence and clinical integrity.
Program launch
For cost plus and local ASO customers, the program officially goes into effect January 1, 2026, or at a group’s renewal date. Importantly, this is an opt-in program for cost plus and local ASO customers. That means employers can choose whether to adopt the new model or continue using Blue KC’s current prior authorization process for cardiac and MSK services. For groups that have already received their 2026 renewal, Blue KC will continue providing its existing prior authorization until the group opts into TurningPoint at a future renewal. This approach gives employers time to evaluate their options and make decisions that best fit their population health goals.
The program has already launched for fully insured groups:
- MSK services began on August 1, 2024
- Cardiac services began on September 1, 2024
JAA, FEP, and National Alliance business segments are excluded from this rollout.
Please connect with your broker or Blue KC representative to learn more about the program, explore the benefits, and determine the best path forward for your organization.
