Our Healthcare Capabilities
We help the government protect those who cannot protect themselves.
Agencies turn to us to help ensure that healthcare facilities all over the United States and its territories are providing patients and residents the quality care they deserve, in accordance with federal and state laws and regulations.
Our healthcare capabilities focus on two primary areas of support: quality assurance & regulatory compliance, and operational improvement.
Quality Assurance & Regulatory Compliance
HMS performs 500+ surveys per year, serving as front-line safety inspectors to ensure that quality and safety standards are being met for patients, residents, and clients receiving care from Medicare and Medicaid certified facilities or those in Veterans facilities. We conduct initial certifications, recertifications, revisits, complaints, Life Safety Code (LSC), and specialty surveys (such as infection control, dementia care, and schizophrenia) in the following settings:
- Skilled Nursing Facilities (Nursing Homes)
- End Stage Renal Disease (ESRD)
- Home Health Agencies (HHAs)
- Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID)
- Hospital (all types)
- Outpatient Physical Therapy/Outpatient Speech Pathology
- Comprehensive Outpatient Rehabilitation Facilities (CORF)
- Rural Health Clinics (RHCs)
- Ambulatory Surgical Centers (ASCs)
- Portable X-ray
HMS helps the Centers for Consumer and Insurance Information (CCIIO) ensure consumers maintain access to affordable, quality health coverage through enforcement of health insurance standards.
- We conduct remote and onsite compliance reviews of Qualified Health Plans (QHPs) offered on the Federally Facilitated Exchange for compliance with Health Insurance Issuer Standards under the Affordable Care Act.
- HMS personnel with expertise in healthcare compliance, health plan and provider operations, fraud, waste, and abuse, as well as nursing and claims administration, review QHP and Stand-Alone Dental Plan (SADP) operational documentation to evaluate compliance with standards related to complaint handling, meaningful access to health plan information, compliance with consumer notification requirements, and maintenance of appropriate access to providers and formulary medications, among other areas.
- Additional studies are designed and performed on the reliability and accuracy of machine-readable provider directory and formulary datasets.
HMS investigates and resolves automated system exceptions associated with Medicare beneficiary enrollments, direct billing, or third-party transactions. Exceptions are reconciled in accordance with the Code of Federal Regulation and CMS guidance to ensure beneficiaries are not incorrectly disenrolled from Medicare. Various avenues of reconciliation of beneficiary premium payments and records are utilized.
- Live Checks: When live checks are in a holding pattern because a bank cannot reconcile the payment for a variety of reasons, our team calls the payee to reconcile the information on the check/remittance advice for resolution.
- Interagency Case Resolution: We work in conjunction with SSA and Medicare to track the length of time interagency cases are resolved between agencies.
- MBI Requests: When beneficiaries feel their MBI has been compromised, they request new MBI numbers. We process these requests to generate a new MBI card that is sent by CMS to the beneficiary. We send confirmation letters to those beneficiaries, daily, with the new information to enable beneficiaries to have uninterrupted services if needed before their new card arrives. This process has a daily deadline for completion.
- Lockbox: We reconcile premiums rejected by the bank for incomplete, inaccurate, or vague information on the payments. We call beneficiaries for resolution. This usually involves determining their correct contact information, which is often not included. In some instances, the name printed on the check is not the beneficiary. Many are third-party payers. We must confirm the information including the name, address, and amount.
- 5515 Debit Voucher Report Exceptions: These exceptions occur when a check is deemed invalid for a variety of reasons: insufficient funds, a closed account, stop payment, bank error, etc. In these cases, we are required to debit beneficiary accounts.
- IRS Error Report Exceptions Reconciliation Process: These are compiled by the IRS in its yearly IRS Error Report because the IRS wrote a check to a Medicare beneficiary, but the beneficiary never cashed the check. Often, the IRS wrote a check to a beneficiary using a misspelled beneficiary name, essentially voiding the check. We review the IRS Error Report exceptions and cross-reference the report’s information with information listed in CMS systems. The IRS Error Report is converted into an Excel spreadsheet for review. If there are differences in information between the IRS Error Report and CMS systems, we must enter updated or corrected information in the appropriate columns of the IRS Error Report spreadsheet.
With a team of highly qualified registered nurse reviewers, HMS performs chart reviews, providing clinical expertise in verifying quality measure data reported by ESRD Seamless Care Organizations (ESCO) to the Comprehensive ESRD Care Model (CEC) and verifying compliance with Bundled Payments for Care Improvement Advanced (BPCI Advanced) Model implementation requirements such as: compliance with the telehealth visit, post-discharge home visits, and SNF three-day stay Medicare payment policy waivers, investigations of unintended consequences to quality of care due to participation in the model, and verification of compliance with beneficiary protections.
HMS subject matter leaders conduct training for surveyors and other entities/groups on a wide range of topics, including program development, compliance monitoring, survey processes, CMS systems administration, and many more. Training can include development of resources and job aides remotely, provision of classroom instruction or group learning activities, onsite visits, or onsite survey coaching and/or performance evaluation.
- HMS training has been proven to improve outcomes in state survey agency performance standards, performance of efficient and effective surveys, and writing of defensible deficiency citations.
- HMS performs individualized assessments to create training materials that are specifically tailored to the needs of each customer and are designed to reach a broad range of learners and learning styles.
- We work with customers to determine the methodology for training delivery that will work best within their budget and training objectives.
HMS has been employed by state and federal governments to provide management consulting to state survey agencies (SAs) to review survey programs and make recommendations consistent with CMS directives, state statute and rule, and best practices used by other SAs.
- HMS SA subject matter leaders have years of experience in SA program management and administration; surveyor training, provider training, and SA training program development; legal processes and review; compliance monitoring; quality assurance; survey processes; federal enforcement; application development; Information Technology (IT) consulting; data analysis and reporting; CMS systems administration; and many other areas.
- HMS management consultants conduct interviews with SA staff and stakeholders, review documentation (e.g., policies, procedures, statutes, etc.), evaluate IT applications and systems, and evaluate survey program components to make recommendations that assist in restructuring or enhancement of SA programs.
HMS performs data validation on large, clinical quality datasets to support CMS’ move to a model which bases payment for care on quality instead of volume. CMS uses datasets to determine payment adjustments to providers. We also create a sample, request and review supporting documentation and medical records for the sampled data, and compare our results with the dataset to determine error rates.
HMS management consultants evaluate state survey agency (SA) practices and organizational issues and assist in restructuring for enhancing their survey programs. HMS developed an application that offers high-level reporting and tracking information to address challenges that SAs were experiencing in efficiently accessing data that would assist the SA in managing and reporting on workload and facilitation of compliance with applicable performance standards. The application:
- Provides real-time metrics for state agency management.
- Includes a dashboard function for state agency performance monitoring.
- Enhances reports from multiple federal systems in a consolidated browser-based application.
- Allows SA staff to quickly view data entered in the CMS ASPEN application.
- Assists the SA in meeting state and federally mandated workload requirements related to the oversight of healthcare providers.