Regulatory

regulatory compliance healthcare industryNMR’s Compliance department continuously accesses resources for updates on regulations regarding national, state and Independent External Review laws applicable to all levels of the review process set forth by:

1. U.S. Department of Health and Human Services

2. U.S. Department of Labor

3. Centers for Medicare and Medicaid Services
(formerly known as the Health Care Financing Administration)

4. Individual State Departments of Insurance, Health, and Labor as applicable.

5. All State and Federal Laws including the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Industry

1. URAC.  URAC’s Independent Review Organization Accreditation Standards require companies to establish and adhere to proper process and procedures for assessment, planning and implementation of all Core Standards and Independent Review Services.

2. NCQA

NMR Policies

1. Confidentiality

The handling of all patient identifiable information will comply with all federal and state laws, regulations, and accreditation standards.

Management, all employees of the company and contractors will keep confidential all patient specific information obtained during the case review process.

Only such information that is necessary to complete the case review process will be obtained.

This information will be used solely for the purposes of case review and quality management.

Access to such information will be limited to only those employees and contractors who need access to implement the case review process. Such information will be shared only with those individuals or entities outside the company who have the authority to receive such information.

All employees with access to confidential information will sign the “Confidentiality Statement/ Workforce Agreement”. Contracts with peer reviewers will include confidentiality. All staff members will complete training on their roles and responsibilities for protecting patient specific information.

2. Prevention of Conflict of Interest

NMR screens all case assignments for any conflict of interest that might involve either NMR personnel, the client and/or the potential Reviewer.  If a conflict of interest is identified, another reviewer is assigned and screened in the same manner.

As a further assurance of conflict prevention, NMR will not permit or provide compensation or anything of value to its Reviewers that would directly or indirectly affect a reviewer’s determination. NMR Reviewers are not paid based on the type of determination they render.

3. Case Review Processing

a) The Decision Process

All of our Reviewers are trained in providing evidence-based decisions, from indexed peer-reviewed medical literature and recognized clinical practice guidelines in addition to utilizing benefit plan language when applicable. The source(s) used are cited in each determination.

b) Review Formats

Decisions are formatted to meet our clients’ requirements. All decisions include, at a minimum:

• Summary of the case
• Discussion of the treatment rendered by the physician under review
• Telephone discussion with the provider, if requested
• Clear decisions and detailed rationales that address the questions posed to our Peer Reviewer
• Plan Language and literature, referenced when applicable

4. Quality Assurance

NMR maintains a quality assurance program that conforms to the most widely accepted standards of the review industry, URAC. It is NMR’s position that prima facie compliance with industry standards represents a minimum level of achievement. Therefore, we maintain a quality control program that promotes continual quality improvement. In practice, this means we constantly work to improve our processes beyond minimal compliance so that we can provide the best possible service to our clients. To ensure client satisfaction, NMR has a highly evolved problem management and quality improvement system.

To manage electronic information flow, NMR utilizes the most recent technologies. Our computer network infrastructure consists of state-of-the-art, high speed, fully redundant servers and firewalls, which provide a combination of fault tolerance and security through encryption well beyond industry standards.