How does a SMRC determine which reviews to perform?

by: Steven Andrews Mar 9, 2018

Question: How does the Supplemental Medical Review Contractor (SMRC) determine which reviews to perform? Does SMRC work for CMS or our Medicare administrative contractor (MAC)?

Answer: The SMRC conducts nationwide medical reviews at the direction of CMS. These reviews may be pre- or postpayment, and the SMRC's focus is based on vulnerabilities identified by CMS internal data analysis, the Comprehensive Error Rate Testing (CERT) program and federal oversight agencies, such as the Office of Inspector General (OIG).

Once the SMRC completes its record review, it notifies CMS of any identified improper payments and/or noncompliance with documentation requests. If payment adjustments are needed, CMS will notify the MACs, who will then initiate claim adjustments and/or overpayment recoupment actions through the standard overpayment recovery process. The provider has a right to appeal the SMRC findings, and all appeals are handled by the MAC. For more information, see CMS' website.

Editor’s note: For more information on Medicare auditing bodies and how to reduce audit vulnerability, register for HCPro’s three-hour Medicare Audits Virtual Workshop: Defend Against Coding Risks webinar with expert speaker Yvette M. DeVay, MHA, CPC, CPMA, CIC, CPC-I, on March 15. Can’t make it to the program live? All registrants receive a free, on-demand copy to train the whole team or review at a later time.

Blog Tags: anti-fraud, CMS, compliance, HHS, MACs, overpayments, RACs

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