How Medical Record Reviews Ensure Effective and Equitable Healthcare Delivery

Federal and state agencies rely on Healthcare Management Solutions, LLC (HMS) to ensure that care being delivered is appropriate, effective, and equitable for all individuals. Medical record review allows HMS and its clients to interpret clinical notations to make sure these goals are met. Michael Gartland, Project Manager and Senior Task Lead of the Marketplace Plan Management Compliance Review, explains the critical role of medical record reviews in effective healthcare delivery. 

What are medical record reviews?

Medical record reviews at HMS include the collection and clinical review of medical records and related information to ensure:

1. Payments for healthcare claims are made only for services that meet all Medicare coverage, coding, billing, and medical necessity requirements;
2. Clinical data used for quality measure reporting, clinical trials, and quality payment program eligibility are complete, accurate, and follow clinical specifications for the practice area;
3. Adherence to patient safety and quality standards for facility certification for the Centers for Medicare and Medicaid Services, and;
4. Adherence to Innovative Care Model program requirements for the Centers for Medicare and Medicaid Innovation.

Why do medical record reviews matter?

Medical record reviews matter for our customers and the patients and beneficiaries they serve, as they provide the details on how and why care has been delivered, and ensure that patient care is being provided in accordance with the standards and requirements established by each program. This is vital to verifying that:

1. The federal trust fund for Medicare is only paying claims that are medically necessary and appropriate;
2. Patients in Medicare-certified facilities are receiving care with proper infection control, medication management, and patient safety measures being implemented, and;
3. Specialty physician groups can monitor outcomes and quality measures for clinical trials, research, and for participation in quality payment programs.

How do medical records protect vulnerable populations?

Individuals are inherently most vulnerable when accessing healthcare services, whether in a hospital, long-term care facility, or in a physician’s office. Commercial, federal, and state payor, oversight, and quality management organizations strive to ensure that care being delivered is appropriate, effective, and equitable for all individuals. Through medical record review, HMS partners with our customers to review and interpret clinical notations to help them ensure these goals are met.

How does HMS conduct its medical record reviews?

HMS conducts its medical record reviews across a variety of programs and therefore tailors its approach for each program and type of review. The vast majority of our medical record review work is conducted remotely by experienced and qualified registered nurse reviewers, allied health professionals, or professional coders supported by our team of administrative, IT specialists, data analysts, and clinical and program subject matter experts. Our reviewers are held to rigorous quality standards and are expected to maintain an inter-rater reliability rate of 95% or greater throughout any project. We primarily use low-code applications that our medical reviewers access remotely. These tools promote a flexible approach to data collection and evaluation and allow for our IT solutions team to design and implement workflow automations for quality assurance and reporting.

What does HMS do differently when it comes to medical record reviews?

HMS takes a customer-focused approach to all of our work, including medical record reviews. We always strive to meet or exceed our customers’ expectations by maintaining high quality standards in medical review while simultaneously finding innovative ways to scale our reviews to conduct a higher volume with fewer resources. Our teams work collaboratively in the design and implementation of our medical review programs and processes to ensure we are meeting customers’ needs, providing valuable information to improve the delivery of healthcare.

Why should someone consider being a medical record reviewer at HMS?

HMS is a great place for qualified medical record reviewers to invest their careers. The work is meaningful, and we have a lot of flexibility in our staffing model. We employ medical record reviewers on a full-time, part-time, or casual basis. Many of our reviewers hold other jobs and will come and do medical record reviews for us to supplement their income. HMS offers a generous benefits package for full-time and certain part-time reviewers. As an employee-owned company, HMS offers the chance to contribute to the growth of the company as an owner, which is really exciting. HMS offers project-specific training and a flexible work schedule. And the vast majority of our medical record reviewers work remotely, which is a really great benefit that enables us to work from anywhere in the country at whatever time we need to work.

What is your role at HMS?

I wear quite a few hats at HMS. I am a project contributor and subject matter expert for our marketplace compliance programs, where I conduct compliance reviews of qualified health plans on the Individual Marketplace. I am also a project manager and lead analyst for our Innovative Care Model Compliance projects and manage our team of medical record reviewers for HMS’s clinical quality validation audit program. Lately, however, much of my time is spent working with HMS’s business development team on customer outreach and market research looking for new medical review opportunities with our federal customers.

What is your favorite thing about working at HMS?

My favorite things about working at HMS are the comradery of our team, the flexibility of the work schedule, the creative and collaborative approach to our work, the opportunity to stretch and expand my skill set through new opportunities, and the chance to lead various projects that may seem a little bit out of my wheelhouse.