Watchdogs

In 2006, Georgia’s Department of Community Health contracted with a private organization — the Georgia Medical Care Foundation (GMCF) — to monitor the quality of its Medicaid waiver program.

The organization has a Herculean task. It makes sure that the more than

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Photos by BARRY WILLIAMS / Special

Sandy Choate (from left), Bruce Kennedy, Gloria Wagner and Jacqui Williams are part of the Georgia Medical Care Foundation’s utilization and compliance review team. The group educates and monitors Medicaid providers to make sure that patients get the care and services they need.

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Gloria Wagner (left) and Jacqui Williams look up information at the Georgia Medical Care Foundation office in Atlanta. ‘I love it that we’re an advocate for the consumer and making sure that patients get the quality care they deserve,’ Wagner said.

1 million recipients of Medicaid in Georgia get the services they need and that the 60,000 to 80,000 physicians offices, hospitals, nursing homes and home-health agencies appropriately provide and bill for that care, without fraud or waste.

The GMCF already had experience in providing medical peer and quality-care reviews for government programs. Because the monitoring job would call for a strong medical background, the sleuthing and assessment skills of a detective, the scrutiny of an auditor, and the compassion of a patient advocate, the GMCF hired nurses.

The team spent several months training with Georgia’s Program Integrity Unit, which had conducted the site reviews previously, and incorporated their methods into a GMCF system.

Sandy Choate, RN, MSHSA, is the medical review manager for the team of 20 nurses and one licensed social worker that conducts field audits throughout the state. She said that her group has learned plenty of lessons in 18 months on the job.

“It’s a different kind of nursing and takes a very seasoned and independent nurse to do this type of work,” Choate said. “You have to be assertive and have good communication skills, because you’ll be sitting right across from the provider and asking to see the records.”

Nurses spend two or three days at each site that they monitor, pulling samples of records and talking to patients. They’ll look for potential adverse reactions to medications, among other things. They also inform service providers about deficiencies they find and file reports with the state.

Experienced eyes

Everybody on the GMCF’s utilization and compliance review team has 25 to 30 years of experience in various nursing fields, including home health, hospital nursing and administration, Choate said. Some have worked for government agencies, the military or in public health.

“Good clinical skills are the foundation of all that we do. You have to have the medical expertise and excellent assessment skills to make quality-of-care judgments,” she said.

Since there’s plenty of paperwork to do, the nurses must also have good computer skills and be organized. Because each nurse covers a geographical district, being open to travel is a must.

“I’ve traveled more in the last year than I did my entire life and [have] seen parts of Georgia I didn’t know existed,” said Gloria Wagner, RN, a GNCF field auditor for the northeast Georgia region. “I love the independence and the fact that you are constantly switching hats and learning something new. Every day is different.”

Wagner often compiles review summaries from home and can be flexible with her hours.

She enjoys educating providers and making sure that they serve their patients well. Wagner feels “exactly like a detective interviewing people and looking for errors and problems.

“We work exactly like auditors, and so the providers are probably glad to see us leave. But we’ve received letters of appreciation that thank us for our level of professionalism and educating them in such a positive manner.”

Bruce Kennedy, RN, MSN, brings his degree and expertise in finance, as well his nursing experience, to his job of training, orienting and supervising the team.

“It’s a challenge to work with so many folks who are out in the field, and [to] try to provide the back-up they need as they work with providers,” he said. “It’s been a real learning experience, but I get a lot of gratification from it.

“I don’t touch the patients as I did when I worked in oncology and adult health, but I know we are making a difference to people who are old or blind, sick or disabled and need care. There is a lot of gratification in that.”

Since the team was started, it has found about $2 million in billing or process errors and has uncovered some suspected cases of fraud.

“We’re serving the state and the health care system and saving the taxpayers money… and I love it that we’re an advocate for the consumer and making sure that patients get the quality care they deserve,” Wagner said.