CMS’ Supplemental Medical Review Contractor Targets Vulnerabilities with Nationwide Medical Reviews

By: Jennifer Colagiovanni, Esq.

Wachler & Associates, P.C.

The Centers for Medicare and Medicaid Services (CMS) contracts with a Supplemental Review Contractor (SMRC) to help lower improper payment rates through audit and medical review activities. Noridian Healthcare Solutions, which is also a Medicare Administrative Contractor (MAC), was selected as the SMRC in 2018.

The SMRC conducts nationwide medical reviews for compliance with coverage, coding, payment, and billing requirements based on CMS-directed topic selections and timeframes. CMS assigns the focus project to the SMRC via a formal notification process. Review topics focus on issues identified through national claims data analysis from the Comprehensive Error Rate Testing (CERT) program, Office of Inspector General (OIG), and CMS internal data analysis, among others.

SMRC medical reviews, referred to as projects, fall within three categories: Healthcare Fraud Prevention Partnership Review, Program Integrity Review, and Provider Compliance Group Review. Each category has a slightly different focus:

• 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

Providers can see where the SMRC’s focus lies by reviewing the current projects posted to Noridian’s website. By way of example, current projects include injections (ophthalmology, transforaminal epidural, facet joint), echocardiography, and total joint arthroplasty among others. A closer look at the echocardiography project reveals the timeframe for the claims subject to review and provides insight about how the project arose, noting that Medicare does not cover ECHOs performed with equipment that provides limited evaluations since such evaluations typically do not provide a permanent image and complete interpretation is not performed. The project details the CPT codes under review as well as the documentation to be included in response to additional documentation requests (ADRs) received. Providers are encouraged to proactively review the current projects list on Noridian’s website to understand the SMRC’s areas of focus and where applicable, evaluate their own practice’s compliance. Understanding the areas of scrutiny and documentation requirements can be a useful tool for both identifying and shoring up vulnerabilities.

So how do you know if you’re the subject of a SMRC review? In general, the SMRC first sends targeted providers an ADR letter in a distinctive green envelope with the Noridian SMRC logo. Upon receipt of requested medical records and supporting documents, the SMRC conducts its 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 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. A provider may also request a Re-Review if they realize they did not submit all the supporting documentation. The Re-Review process is intended to give providers an opportunity to submit additional documentation for review, after which a new final results letter is issued.

Outside of the Discussion & Education and Re-Review Process, providers should remember that they generally also have the right to appeal the SMRC’s Review Results or any overpayment demands based on the Review Results within certain timeframes.

For additional information regarding SMRC medical review activities or assistance with Medicare audit appeals, please contact Jennifer Colagiovanni, Esq., of Wachler & Associates, P.C., at (248) 544-0888.