BEST PRACTICES FOR MANAGED CARE
The CLNC®'s Role in Evaluating HMO Physician Compliance
by Pam Harris
Physician compliance with Standards of Care and best practices is becoming a critical issue. With medical malpractice litigation booming, physicians in both private practices and HMOs are shifting their focus away from traditional episodic care because of growing concerns about deficits in overall quality of care. At the same time, companies burdened with unbearable healthcare costs, including costs of general and chronic healthcare and workers' compensation, are demanding that healthcare organizations develop Standards of Care for physicians in order to justify care and manage the financial burden. As people live longer, management of chronic diseases and other chronic health concerns have heightened the need to monitor physicians' care.
As a CLNC®, you need to be aware of the increasing focus on monitoring physicians' care in general medical practice, office practice and chronic disease management. Nowhere is this trend more evident than in HMOs. Best practices for HMO physicians cover billing practices, physician office care and physician care. These areas are monitored by HMO departments handling claims, quality improvement, utilization and member services.
In addition, best practices and Standards of Care are being addressed at the state and federal levels for Medicare and Medicaid participants, as well as within corporations that have healthcare benefits for their employees. At the state level some states have begun educating physicians about best practices and performance standards. Also, state governments are developing contracts that outline an HMO's responsibility for the performance of its physicians and ancillary contractors. The oversight language covers everything from medical best practices to the administrative process, including utilization review and quality improvement.
State and federal governments monitor HMO physicians in several ways:
Health Plan Employer Data and Information Set (HEDIS) – This mandatory annual audit covers HMO physicians' standards of practice for preventive care and routine visits. It evaluates physician care and monitoring of immunizations, physical examinations, pregnancy care, comprehensive diabetic care and breast cancer preventive care, just to name a few.
HMOs use this tool to determine which physicians or physician offices are not meeting their performance standards. HMOs can also use HEDIS to develop and monitor quality improvement projects designed to enhance overall care and individual physician care throughout their network.
State monitoring of the credentialing process – Some states require HMOs to perform site visits to primary care physician
(PCP) and OB-GYN offices, as well as high-volume specialist offices, prior to credentialing or recredentialing. Depending on the state, these site visits can cover employee and patient safety, access to medical records and other privacy requirements.
Occupational Safety and Health Act of 1970 – This legislation encourages states to partner with the U.S. Department of Labor's Occupational Safety and Health Administration (OSHA) to develop and operate their own job safety and health programs (section 18, Occupational Safety and Health Act). OSHA approves and monitors such plans for about half the states. Though often overlooked, OSHA safety regulations affect HMOs and their physicians on issues ranging from blood borne pathogens to workplace violence (www.osha.gov).
Health Care Quality Improvement Act of 1986 – Enacted in response to the increasing incidence of medical malpractice, this legislation was designed to prevent incompetent physicians from moving from state to state without disclosure or discovery of their past performance. The law established a professional peer review process to determine if a physician's Standards of Care were questionable.
Physician compliance is an issue that needs to be addressed nationally in order to improve the quality of care for all population sectors, from those having commercial insurance to the uninsured. By using the resources and benchmarks listed above, you can assist your attorney-client in determining whether an HMO physician is compliant with standards for general medical practice, office practice or chronic disease management.
Pamela Harris, RN, BSN, CLNC is the owner and president of Harris Compliance Solutions, Inc. in Michigan. Her areas of expertise include HMO insurance, managed care, critical care, home care, quality improvement and utilization review.
CLNC® Q&A
I Am a Nurse Who Has Been out of Clinical Practice for Years.
Can I Still Succeed as a CLNC®?
The answer is an emphatic "YES," especially if you want to work behind the scenes as a consulting expert rather than as a testifying expert. Interestingly, most medical malpractice cases deal with basic nursing issues – issues you learned in nursing school, such as failure to recognize a change in patient condition, failure to report that change to the doctor and failure to follow the chain of command in getting someone to evaluate and treat the patient. Even if you have been out of clinical practice for some time, you still know and easily recognize these basics.
Some cases do address specific specialty issues. In those situations you would subcontract with another CLNC® who is clinically active in that specialty. You might ask her to review all or part of the case, or simply ask questions about specific case issues. You can find CLNC®s who are willing to help you with cases involving their specialty by networking and building mutually beneficial relationships. You would pay the subcontracting CLNC® 30-50% of your hourly fee, thereby still being handsomely rewarded for managing the professional relationship with the attorney.
Some case reviews involve medical issues as well as nursing issues. On these cases you would:
Conduct preliminary research on the disease process or injury in order to develop a basic understanding of appropriate evaluation, management and treatment, much as you did in nursing school when you learned each body system and its potential disease processes.
Review the records, applying the knowledge gained from your research.
Render an opinion based on your research, experience and the expertise of the CLNC® subcontractor where applicable.
Report your initial opinions to your attorney-client first and recommend the issues the attorney should address with the medical expert.
Another vital component in succeeding as a CLNC® is your ability to do nursing research on the Standards of Care. This is a huge area where medical malpractice attorneys are always in need of a good consultant. The Standards of Care are the basis for evaluating a healthcare provider's actions. You can easily research standards even if you are no longer clinically active.
Finally, medical malpractice cases are only a fraction of the cases out there. As a CLNC® you could be involved in numerous other types of cases, such as personal injury, products liability, toxic tort and criminal cases. In such cases, you would usually be asked to read and translate the medical records, explain the medical treatment and produce a brief or comprehensive chronology, depending on your attorney-client's issues and requirements.
You can provide all these services and earn a handsome income as a CLNC® without being clinically active. The sky is the limit. Go for it and join the successful full-time CLNC®s who left clinical practice and are glad they did.
