Advocacy + Stewardship + Safeguard
Myers and Stauffer provides meaningful careers where our associates know their work truly makes a difference in the lives of others. This month, we feature Kelly Robertson, BSN, RN (Health Care Senior Manager, Kansas City), as she talks about how her clinical work as a registered nurse shaped her views about her role at Myers and Stauffer and reinforced her deep commitment to the well-being of others, especially the vulnerable and fragile populations our clients serve.
“Myers and Stauffer’s audits of Medicare Advantage organizations and Programs of All-Inclusive Care for the Elderly (PACE) organizations help ensure plan enrollees and participants receive the access to care they need and request. These audits can have a significant effect on a large number of at-risk individuals. For example, in the case of audits of PACE programs, an all-inclusive care model, the individuals enrolled qualify for services by virtue of being frail and elderly citizens. Because many of the PACE organizations are for-profit business models, there is significant incentive to contain costs related to provision of care.
Our work as an audit contractor to the Centers for Medicare & Medicaid Services (CMS) has uncovered significant concerns with participants’ access to care through inappropriate denials of services and prescription drugs, inappropriate restrictions of services, failure to assess the need for a service or other areas of non-compliance with CMS requirements. In some instances, the restrictions on or failure to provide services have resulted in harm to the participant.
Clinicians have observed situations such as untreated wounds leading to amputation, ignored concerns of vision changes resulting in blindness, denial of chemotherapeutics due to expense, refusal of mobility equipment resulting in falls and fractures, and more.
Unlike many audits that focus on a past time period, finances, or cost savings, the program review audits can be immediately impactful to both the operations of the organizations under review and to the participants receiving care. Reviews typically cover a recent period to get a real-time look at how the organizations are operating. All forms of non-compliance identified in the audit require the organization to develop corrective action plans, which audit teams then review and CMS account managers audit until programs achieve compliance. Significant findings related to non-compliance have prompted monetary penalties for these organizations and/or suspension of participant enrollment. Accordingly, audit findings can have significant financial implications to the organizations under review and can also lead to immediate changes in the care participants receive. Issues identified through our audits become public information.
As a nurse whose practice once centered on helping people in a clinical setting, I have seen how nursing care has a tangible effect on patients. Although PACE audit work is different, I enjoy it because I see how our work connects directly to patient care. When reviews identify that PACE programs are not adhering to standards of care, my work takes on an advocacy component that parallels my experiences in former clinical roles. Seeing the implementation of corrective action or other sanctions reinforces the reality that the results of our audits are having an immediate effect, for the better, on the participants served by these programs.”
Get to Know Kelly
Kelly is a nurse reviewer with previous experience as an independent legal nurse analyst consulting on criminal and medical malpractice cases. She has an extensive background in inpatient pediatric and adult oncology, intensive-care settings, and pre-surgical/post-surgical care. Additionally, Kelly has experience in pediatric outpatient specialty clinics.
Myers and Stauffer is proud to help our clients serve those who are most vulnerable. Our staff feel empowered to know that their hard work and dedication each day makes a difference. We believe it and so do the millions of individuals helped by the clients we serve. We will release new stories each month highlighting associates and their stories. Follow along with our LinkedIn, Twitter, and Instagram for more information.