Healthcare

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)
  • Hospice
  • 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.

• • 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.