Wachler & Associates Health Law BlogA Guide to SMRC Audits
SMRC audits can be a difficult and baffling ordeal for a provider. They can last for months or years with very little information provided to the healthcare provider but can have devasting impacts. The Supplemental Medical Review Contractor, or SMRC, is a contractor with the Centers for Medicare & Medicaid Services (CMS) that performs a variety of Medicare and Medicaid audit and medical review tasks. Noridian Healthcare Solutions, which is also a Medicare Administrative Contractor (MAC), was selected as the SMRC in 2018 and remains the current SMRC. The SMRC conducts nationwide medical reviews of Medicare Parts A and B, DMEPOS, and Medicaid claims for compliance with coverage, coding, payment, and billing requirements.
The SMRC’s audit areas are chosen by CMS and are referred to as “projects.” The focus of the medical reviews may include areas identified by CMS data analysis, the Comprehensive Error Rate Testing (CERT) program, professional organizations, and federal oversight agencies. At the request of CMS, the SMRC may also carry out other special projects. Not every SMRC project is created equal. Some SMRC projects are intended as program integrity audits to identify suspected fraud or are intended as medical necessity reviews to identify overpayments, while other SMRC projects are simply data collection and analysis meant to inform future CMS policy. Where a provider is subject to a SMRC audit, knowing which project the audit falls under can provide valuable information.
Where CMS assigns a project to a SMRC, the SMRC first sends targeted providers an Additional Documentation Request (ADR) letter, usually in a distinctive green envelope with the Noridian SMRC logo. Upon receipt of the requested medical records and/or supporting documents, the SMRC conducts the review based on the analysis of national claims data, statutory and regulatory coverage, and coding, payment, and billing requirements. Once the review is complete, the provider should receive a Review Results Letter. A provider may sometimes be given 14 days to request a voluntary Discussion and Education session with the SMRC. The provider generally also can appeal the SMRC’s findings directly to the SMRC. Where a SMRC denies an appeal, it may refer the matter to the local MAC to collect the alleged overpayment, which is generally subject to the Medicare claims appeal process. If the SMRC suspects fraud, it may also refer the matter to CMS or other government agencies.
Providers should be aware of the following issues they may encounter during a SMRC audit. First, the provider may go several months without receiving a response to a SMRC appeal, or may receive no response at all. A provider who expects, but has not received, a SMRC response should consider carefully checking their Medicare EOBs for activity their MAC may have taken based on the SMRC audit and note any appeal deadlines. Further, as a national contractor, the SMRC may not understand local rules, such as local LCDs or state scope of practice rules. A provider who is subject to a SMRC audit should carefully evaluate their options and response.
According to the current SMRC, the following are ongoing projects under review as of June 2022:
- Transforaminal Epidural Injections
- Malnutrition
- Electrodiagnostic Testing Axial Muscles and Spinal Levels
- Vitamin D Testing
- Carotid Artery Screening/Testing
- Audio Only Telehealth Services During the PHE
- SNF 3-Day Stay Waiver PHE
- Potentially Unnecessary Surgeries
- Traditional Telehealth
- E&M No Response Providers DME
- EDX Diabetes
- Total Joint Arthroplasty
- Schizophrenia in SNFs
- Echocardiography
- Treatment of Chronic Venous Insufficiency
- E&M Dermatology Services
- Neurostimulator Implantation
- Home Health
- Cataract Surgery
- Surgical Dressings
- Facet Joint Injections
- Inpatient Psychiatric Facilities
- Ostomy Supplies
- Orthopedic Footwear
- Outpatient Therapy
- Ophthalmology Injections
- Endomyocardial Biopsy with Right Heart Catheterization
For over 35 years, Wachler & Associates has represented healthcare providers and suppliers nationwide in a variety of health law matters, and our attorneys can assist providers and suppliers in understanding SMRC audits and other types of payor reviews. If you or your healthcare entity has any questions pertaining to healthcare compliance, please contact an experienced healthcare attorney at 248-544-0888 or wapc@wachler.com.