June 11, 2021
The year 2020 saw much less medical review auditing, including a CMS suspension of audits between March 30 and August 3 of 2020. However, with the lifting of the CMS suspension, the CMS Supplemental Medical Review Contractor (SMRC) has resumed auditing in full swing.
Who is the SMRC? Noridian Healthcare Solutions was selected as the SMRC in 2018. As the SMRC, Noridian conducts nationwide medical reviews of Part A, Part B, and DME claims.
What can it review? Any providers or suppliers of Part A, Part B, and DME services or supplies can be audited by the SMRC if a medical review target is assigned to it by CMS. The SMRC is intended to be a “centralized medical review (MR) resource that can perform large volume MR nationally . . .”
Why are providers chosen for audit? Overall, the main reason providers are targeted for an SMRC audit is if CMS data shows that the provider is billing specific codes at rates that are outliers when compared to the national average.
What is the SMRC Auditing? SMRC review targets are assigned by CMS, and focus on analysis of national claims data as identified by Federal agencies, such as the Office of Inspector General (OIG), the Government Accountability Office (GAO), other internal CMS data analysis, Comprehensive Error Rate Testing (CERT), Program for Evaluating Payment Patterns Electronic Report (PEPPER), and other sources.
What are Noridian SMRC’s Current Projects? Noridian lists its current projects as follows:
- Botulinum Toxins
- DME Supplies in Non-Covered SNF
- DRGCOVID 20% Add On Payment
- DRG Thyroid, Parathyroid and Thyroglossal Procedures
- Hospice Portfolio
- Inpatient Rehab Facility (IRF)
- Inpatient Rehabilitation Facility Stays (IRF) Longer Length of Stay (LOS)
- Intravenous Immune Globulin (IVIG)
- Outpatient Hyperbaric Oxygen Therapy (HBO)
- Skilled Nursing Facility (SNF)
- Specimen Validity Part 2
- Spinal Cord Stimulator
- Therapeutic Shoes for Diabetics
- Therapy Reviews
- Transforaminal Epidural Injections
What do the SMRC’s audits look like? Noridian will initiate an SMRC by sending an Additional Document Request (ADR) in a distinctive green envelope with the Noridian SMRC logo. Once the review is completed, the provider will receive a Review Results Letter. In some cases, the provider will be given 14 days to request a Discussion and Education session (D & E period). The D & E period allows for discussion of the medical review findings, education to avoid future denials and an opportunity to submit missing documentation.
When the project is completed, Noridian will forward any identified overpayments to CMS who will direct the Medicare Administrative Contractor to begin overpayment recoupment actions. At this point, the provider must decide whether to begin the CMS claims appeal process.
If you are a provider that fits into one of the current SMRC project categories, it is a good time to make sure your documentation and coding are up to par. If you have already received an SMRC audit, the best defense begins immediately prior to sending in the requested records. At this early stage, the focus should be on the production of complete, well organized records, development of clinical arguments regarding the necessity of care, the addition of physician and/or expert support for the cases, the identification of technical issues, and more. A well-developed initial response can result in the SMRC being resolved without overpayments or with fewer overpayments.
Let us know if Nexsen Pruet can help guide you through this process.