The Centers for Medicare & Medicaid Services (CMS) contracts with a Supplemental Medical Review Contractor (SMRC), which 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. 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 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.
SMRC audits are referred to as projects and there are three categories of SMRC project reviews:
- Healthcare Fraud Prevention Partnership (HFPP) Review: Based on fraud, waste, and abuse trends identified by the HFPP.
- Program Integrity (PI) Review: Focused on alleged possible falsification or other evidence of alterations of medical record documentation including, but not limited to: obliterated sections; missing pages, inserted pages, or white out; excessive late entries; evidence that services billed for were not provided and/or provided as billed; or patterns and trends that may suggest potential fraud, waste, and abuse.
- Provider Compliance Group (PCG) Review: Based on an evaluation of a beneficiary’s information and supporting medical records to ensure that payment is made only for services that meet all Medicare coverage, coding, and medical necessity requirements.
CMS determines review topics and timeframes, then assigns the focus project to the SMRC via a formal notification. In general, the SMRC first sends targeted providers an Additional Documentation Request (ADR) letter in a distinctive green envelope with the Noridian SMRC logo. Upon receipt of 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 will 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 Discussion and Education session is meant to allow for discussion of the medical review findings, education to avoid future denials, and an opportunity to submit missing documentation. Providers should remember that they generally also have the right to appeal the SMRC’s Review Results or the any overpayment demands based on the Review Results within certain timeframes.
According to Noridian, the current SMRC, the following are ongoing projects under review as of February 2022:
- Audio Only Telehealth Services During the PHE
- Carotid Artery Screening/Testing
- Cataract Surgery
- DME Supplies in Non-Covered SNFs
- E&M No Response Providers DME Part II
- Echocardiography
- EDX Diabetes
- Electrodiagnostic Testing Axial Muscles and Spinal Levels
- Endomyocardial Biopsy with Right Heart Catheterization
- Facet Joint Injections
- Facility Chronic Care Management (CCM)
- Home Health
- Inpatient Psychiatric Facilities
- Inpatient Rehabilitation Facility Stays (IRF) Longer than Length of Stay (LOS)
- Malnutrition
- Ophthalmology Injections
- Orthopedic Footwear
- Ostomy Supplies
- Outpatient Therapy
- Surgical Dressings
- Total Joint Arthroplasty
- Traditional Telehealth
- Transforaminal Epidural Injections
- Vitamin D Testing
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.