Registered Nurses Are Vital to Healthcare Management Solutions’ (HMS’) Medical Reviews & Compliance Audits

Registered Nurses Are Vital to Healthcare Management Solutions’ (HMS’) Medical Reviews & Compliance Audits

  • January 5, 2022

Healthcare Management Solutions, LLC’s’ (HMS’) audit and compliance services, including medical record and non-medical record compliance audits, are central to protecting vulnerable populations. Throughout such engagements, HMS has deployed highly skilled registered nurses (RNs) as vital subject matter leaders in this critical line of work.

“Having registered nurses on our clinical staff provides a high level of expertise,” explained HMS President & Owner Leah Heimbach. “They contribute a deep understanding of the healthcare continuum, care pathways, and how care is delivered. We greatly value what our RNs bring to the table.”

Their role was especially important when HMS joined a team tasked by the Centers for Medicare and Medicaid (CMS) in December 2018 to conduct monitoring and compliance of the Bundled Payments for Care Improvement Advanced (BPCI Advanced) Patient Care model. As a subcontractor, HMS’ BPCI Advanced medical record reviews ensure that Medicare beneficiaries are made aware they are receiving care within the model, they continue to have power of choice in their selection of the best downstream and post-acute care providers, and that the quality of care provided is not diminished due to participation in the patient care model.

HMS’ BPCI Advanced team includes RN reviewers for the BPCI-A engagement that have masters degrees and leadership experience in leading quality, compliance, and health informatics initiatives. Their expertise in value-based care models, Medicare payment policy waivers and other requirements affecting beneficiaries has been invaluable. BPCI Advanced work isn’t simply about medical record review but is also focused on programmatic compliance with model requirements.

Medical record review, as well as non-medical record compliance audits, are fundamental to HMS’ service offerings. We evaluate health plans’ federal regulatory compliance, reviewing administrative and operational documentation. In addition to high-level RNs, our teams include certified fraud examiners, CPAs and other staff experienced in plan implementation, oversight, quality assurance, and compliance.

For the BPCI-A program, our compliance audit was staffed by two types of experts: clinical reviewers and quality analysts. Clinical reviewers are responsible for reviewing patient education materials, implementation of care redesign, and medicare payment policy waivers, for example. Quality analysts support the clinical reviews by gathering documentation, which is a very important aspect of monitoring BPCI-A compliance that involves enormous volumes of material, such as planning notes and care transition notes from physicians’ offices. A lot of work goes into monitoring costs and the quality of care that’s delivered to beneficiaries through the BPCI-A model.

Beyond the BPCI-A model work, HMS conducts a variety of other compliance audits and quality reviews — and a team of nurse reviewers is central to that work. Reviewers must be familiar with using care-quality databases, analyzing very detailed medical data, and comparing medical records to validate quality measures. We also take certain measures and operationalize them, using HMS’ low code data abstraction technology solution as a review tool.

Similarly, HMS provides clinical data validation audit services for the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery and Intermacs quality registry databases. For this review, HMS’ integrated clinical and IT teams worked together to develop custom clinical abstraction tools and protocols to validate selected data variables contained within the clinical registry. HMS’ integrated approach provides innovative, customized solutions that work for a variety of registries and databases. 

HMS has the capacity to conduct 100% remote reviews, which gives both our RN reviewers and the customers flexibility. This capability has been especially important due to the public health emergency caused by COVID, which has put healthcare facilities and providers’ offices under intense pressure.

For RNs who have experienced COVID-related burn-out or have been seeking respite from those high-pressure conditions, HMS’ medical review and compliance audit work offers a great opportunity to leverage their knowledge and experience while continuing to make a positive impact in the healthcare field. HMS also employs qualified RNs on a part-time basis for those who want to continue in their present role but earn supplemental income and achieve a better work-life balance.

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