The Centers for Medicare and Medicaid (CMS) has established multiple levels of subcontractors to identify and minimize evidence of improper payments. Each provider has a Medicare Administrative Contractor (MAC). Currently the MACs include: is Noridian Healthcare Solutions, LLC (Noridian), CGS Administrators, LLC (CGS), National Government Services, Inc. (NGS), Novitas Solutions, Inc. (Novitas), Palmetto GBA, LLC (Palmetto), and First Coast Service Options, Inc. (First Coast). View coverage by state.

In addition to the contractor assigned to your organization, CMS has appointed a Supplemental Medicare Review Contractor (SMRC). The SMRC conducts nationwide medical reviews of Medicaid, Medicare Part A/B, and DMEPOS claims to determine whether claims follow coverage, coding, payment, and billing requirements. CMS has awarded the current SMRC contract to Noridian.

It is important to understand that regardless of which MAC reviews your claims for payment, Noridian is the designated SMRC auditor. You might receive notification from Noridian about being chosen for a SMRC review. Take note as SMRC letters are always time sensitive. Make sure your Business Office and clinical team are aware if you get a letter from the SMRC!

WHAT DOES THE SMRC LOOK FOR?

As the SMRC, Noridian reviews and then supports a variety of tasks aimed at lowering improper payment rates and increasing efficiencies of the medical review process for CMS. Noridian conducts nationwide medical reviews on Medicare Part A, Part B and DME. Using the applicable statues, laws, regulations, national and local coverage determination (LCD) policies, and coding guidance to determine whether Medicare claims have been billed correctly. Information is gathered electronically from a number of methods. Remember, all the information on your claim forms is available to be reviewed. CMS internal data analysis, the Comprehensive Error Rate Testing (CERT) program, and the Program for Evaluating Payment Patterns Electronic Report (PEPPER) are examples.

Posted on the Noridian website is a recent SMRC focus for Medicare Part A: 01-056 SNF 3 Day Stay Waiver PHE Notification of Medical Review. The SMRC is conducting post-payment reviews of Medicare Part A Skilled Nursing Facility (SNF) claims on dates of service from March 1, 2020 through December 31, 2021. Remember, this was the timeframe when COVID-19 was more prevalent in your facilities, and you may have used the Waiver for residents for skill-in-place, or for less than 3-day hospital stays.

WHAT MIGHT HAPPEN IF I AM CHOSEN BY THE SMRC FOR REVIEW?

  • If you receive a letter of review, you will have a clearly identified target date to submit documentation. Following the timely submission of the requested data, the SMRC will conduct the review.
  • Once the review is complete, you will receive a Review Results Letter.
  • You may sometimes be given 14 days to request a voluntary Discussion and Education Session with the SMRC. The Discussion and Education session is provided to allow for discussion of the medical review findings, allow the SMRC to provide education to avoid future denials and an opportunity to submit missing documentation.
  • If you disagree with the findings, you have the right to appeal the SMRC’s Review Results within specific, identified timeframes.
  • There might be overpayment demands based on the Review Results, also with timeframes.
  • You might have a follow up review after you participate in training with the SMRC.
  • You might pass with flying colors.

WHAT SHOULD I DO TO BE PREPARED?

  1. Be aware of the SMRC current projects related to Medicare Part A. Check out the Documentation Requirements and be prepared to submit all documents in order listed if you get notification in a letter.    
  2. Verify that you have handled the use of the PHE Waiver correctly. This may be an opportunity to be aware of your risk if you used the waiver for skill-in-place and have not conducted any audits of your documentation.
  3. If you get a letter and want to have a review of your documentation before you submit, or if you submit and have an adverse result, LW Consulting, Inc. (LWCI) can assist to identify your appeal possibilities.