HIPAA · HITECH · NCQA · CMS · DMHC · THE JOINT COMMISSION · HITRUST/NIST/SOC 2

Compliance Isn’t Optional – Efficiency Is.

Internal Audit That Moves Metrics—Not Paperwork.

QMTRY Audit Section
  1. QMTRY’s internal auditing team backs your Provider problem spaces end-to-end— Revenue & Cash (Denials), Quality/Stars & VBC, Data & Interoperability, Compliance & Audit, and Pharmacy Adherence.
  2. We validate data, measures, and controls: pinpoint denial/DNFB waste; confirm HEDIS/Stars build and gap lists; harden FHIR pipelines and lineage; and package evidence.
  3. Every finding turns into an actionable worklist—A/R queues, outreach files, dashboards, model cards—tracked to closure with KPIs: ↓ denials & DNFB, ↑ clean-claim rate & cash yield, ↑ Stars/HEDIS & PDC/SUPD, ↓ time-to-insight, fewer audit findings.
QMTRY Providers Table
Providers — Problem Spaces
Revenue & Cash (Denials)
Problem Signals
  1. Margin pressure; rising denials
  2. Slow cash; DNFB growing
  3. Confusing payer rules
QMTRY Services
  1. Rev-cycle & payment-integrity analytics
  2. 835/837 recon; CARC/RARC mapping
  3. Coding & compliance QA
Tangible Deliverables
  1. Denial heatmaps & playbooks
  2. A/R auto-work queues
  3. Audit-ready RCM dashboards
Impact / KPIs
  1. ↓ Denial rate, ↓ DNFB
  2. ↑ Clean-claim rate
  3. ↑ Cash yield
Quality / Stars & VBC
Problem Signals
  1. Weak HEDIS/Stars performance
  2. Care gaps not closing
  3. VBC readiness uncertain
QMTRY Services
  1. HEDIS/Stars analytics & measure build
  2. Gap-closure stratification & outreach
  3. Provider performance coaching
Tangible Deliverables
  1. Member gap lists & chase files
  2. Measure run-rates & cohort drilldowns
  3. Provider scorecards
Impact / KPIs
  1. ↑ Gap closure %
  2. ↑ Measure compliance
  3. ↑ VBC shared savings
Data & Interoperability
Problem Signals
  1. Fragmented EHR data
  2. ADT/CCD/FHIR issues
  3. Slow feed onboarding
QMTRY Services
  1. FHIR integration & ingestion
  2. Canonical data model & ELT
  3. Data quality checks (GX)
Tangible Deliverables
  1. Data dictionary & lineage map
  2. Validation logs & exceptions queue
  3. Run-books & diagrams
Impact / KPIs
  1. ↓ Data defects
  2. ↓ Time-to-insight
  3. Faster onboarding
Compliance & Audit
Problem Signals
  1. HIPAA/NCQA audit risk
  2. Missing model/process evidence
  3. Access control gaps
QMTRY Services
  1. Continuous compliance monitoring
  2. Evidence bundle generation
  3. Access & activity auditing
Tangible Deliverables
  1. Model cards & KPI definitions
  2. Audit logs & control matrices
  3. Risk register & remediation
Impact / KPIs
  1. Audit-ready artifacts
  2. ↓ Findings / exceptions
  3. Policy → evidence traceability
Pharmacy Adherence
Problem Signals
  1. Medication adherence issues
  2. SUPD outliers
  3. PDC below target
QMTRY Services
  1. PBM & pharmacy analytics
  2. Adherence program design
  3. Refill / outreach segmentation
Tangible Deliverables
  1. PDC distributions & risk tiers
  2. SUPD lists (member/provider)
  3. Outreach queue exports
Impact / KPIs
  1. ↑ PDC
  2. ↓ SUPD gaps
  3. ↑ Drug-measure STARS

Controls & Measure Mapping

We map HIPAA/HITECH, NCQA/HEDIS, and CMS Stars to your organization and tech stack, assign owners & SLAs, and link every policy to a concrete control and test.  No “tribal knowledge,” Just living control map. 

See Evidence Flow

Continuous Evidence & Data QA

Pipelines (dbt + Great Expectations) generate evidence as they run—tests, approvals, lineage, and exceptions—so audits pull from a single source of truth, not screenshots.

See Evidence Flow

Audit-Ready Evidence Pack

One export with policies, control map, test runs, screenshots, KPI definitions/model cards, DPC checklists, and sign-offs—fully timestamped and traceable (policy → control → test → evidence).

Request Sample Bundle

Health Plan Audits That Lift Stars, Seal Leaks, and Speed Decisions

QMTRY Payer Value Chain
  1. We pressure-test the payer value chain end-to-end— Stars/CAHPS/HOS drivers and contract rollups; network adequacy and directory hygiene; pre/post-pay integrity and FWA exposure; UM/prior-auth throughput; data governance and evidence.
  2. Findings don’t die in binders: we convert them into command-center rollups, driver trees, adequacy heatmaps, edit-rule packs, TAT dashboards, SIU feeds, and audit-ready evidence bundles.
  3. The result is what executives actually feel: ↑ overall STAR rating & bonus eligibility, ↓ improper payments & penalties, ↑ first-pass accuracy, ↓ TAT and backlogs.
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From Signals to Proof—Fast.

We turn provider and payer noise into audit-ready operations: denials down, Stars/HEDIS up, TAT down—backed by evidence you can hand to an auditor or a CFO without blinking.

  • Providers: ↓ denials & DNFB • ↑ clean-claim rate & cash yield • ↑ HEDIS/Stars • ↓ time-to-insight
  • Plans: ↑ overall STAR rating & bonus eligibility • ↓ improper payments & penalties • ↑ first-pass accuracy • ↓ TAT/backlogs
  • Signals → Services → Deliverables → KPIs — plumbing stood up, worklists live, evidence bundled.
  • Artifacts: heatmaps, driver trees, gap lists, edit-rule packs, scorecards, model cards, lineage, and a one-click Audit-Ready Pack.
Stars/HEDIS Sprint Denials Triage Audit-Ready Pack

Stars/HEDIS Sprint (4–6 weeks)

Baseline → top 5 fixes → outreach queues → live scorecard.

Open Stars/HEDIS Sprint Repo

Denials Triage (30 days)

Top 10 root causes → A/R auto-queues → yield KPIs you can track.

Open Denials Triage Repo

Payer Ops Throughput

Intake-to-outcome maps → TAT dashboard → automation shortlist.

Open Claims Pipeline Repo

Controls & Measure Mapping

Map HIPAA/HITECH, NCQA/HEDIS, and CMS Stars to org & stack. Assign owners, SLAs, and tests so policy ⇢ control ⇢ evidence isn’t “tribal knowledge.”

Open Controls Mapping Repo

Continuous Evidence & Data QA

Pipelines (dbt + Great Expectations) emit tests, approvals, lineage, and exceptions as they run—one source of truth, not screenshots.

Open Evidence Pipelines Repo

Audit-Ready Evidence Pack

One export: policies, control map, test runs, KPI definitions/model cards, screenshots, and sign-offs—timestamped and navigable.

Open Evidence Pack Repo

Evidence, Not Screenshots

KPI Dictionary & Model Cards

Every metric defined, versioned, and tied to its source.

Open KPI Repo

Lineage & Data Contracts

From FHIR/HL7 ingest to dashboard—tracked and testable.

Open Lineage Repo

Control Map & Tests

Policy → control → test → run history, all in one trail.

Open Controls Repo

Audit-Ready Pack

A single, timestamped export for auditors & execs.

Open Evidence Repo
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