What Is a Supplemental Medical Review Contractor

Given the timelines and steps listed above, please do not call the DME DMA until at least 140 calendar days have elapsed from the date the documentation was sent to find out the status of the JCC review. Q: How does the Supplementary Medical Examination Contractor (MSRC) determine which examinations to perform? Does the CRSM work for CMS or our Medicare Administrative Contractor (MAC)? What can he verify? Any supplier of Parts A, B and EMR services or supplies may be subject to verification by the RMHC if they are assigned a medical examination target by CMS. The SMRC is considered a „centralized medical examination (RM) resource that can perform high-volume MRI at the national level.“ A: The RMHC conducts medical examinations nationally on the instructions of the CMS. These reviews can be conducted before or after payment, and the RMHC focuses on vulnerabilities identified by internal cmS data analysis, the Comprehensive Error Testing Program, and federal regulators such as the Office of the Inspector General. Who is the CRSM? Noridian Healthcare Solutions was selected as an SMRC in 2018. As a CRSM, Noridian conducts nationwide medical reviews of Parties A, B and EMR claims. Once the RMHC has completed its file review, it notifies CMS of any inappropriate payment detected and/or non-compliance with documentation requests. When payment adjustments are required, CMS notifies the MACs, who then initiate claim adjustments and/or overpayment recovery actions through the standard overpayment recovery process. The provider has the right to appeal the results of the CRSM and all calls will be handled by the MAC. For more information, visit the CMS website. As a CRSM, Noridian performs and/or supports a variety of tasks aimed at reducing inappropriate payment rates and increasing the efficiency of the medical examination functions of the Medicare and Medicaid programs. What do RMHC audits look like? Noridian initiates a CRSM by sending a Request for Additional Document (ADR) in a distinctive green envelope with the CRSM`s Noridian logo.

As soon as the exam is completed, the supplier receives a letter of exam result. In some cases, the provider has 14 days to request a discussion and training session (D&E period). The D&E period allows for discussion of the results of medical examinations, education to avoid future rejections, and submission of missing records. Using CMS-driven topic selections and timelines, Noridian conducts nationwide medical examinations (Part A, Part B, and EMR) in accordance with all applicable laws, laws, regulations, national and local guidelines to determine coverage and coding guidelines to determine whether Medicare claims have been billed in accordance with coverage practices, coding, payment and invoicing. These reviews are assigned through formal CMS advice and focus on the analysis of national claims data issues identified by federal agencies, such as the Office of the Inspector General (Big Big Management), the Government Accountability Office (GAO), internal CMS data analysis, the Comprehensive Error Rate Testing (CERT) program, and professional organizations and/or analytical reports such as the First-Look report. Analysis Tool for Hospital Outlier Monitoring. (FATHOM) and electronic reporting (PEPPER). Assessments are based on project types from the Provider Compliance Group (PCG), Program Integrity (PI) and Healthcare Fraud Prevention Partnership (HFPP). What is the SMRC audit? The SMRC review objectives are assigned by cms and focus on analyzing national loss data identified by federal agencies such as the Office of the 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. This situation is considered a reopening and the MAC EMR sends the documents submitted to the SMRC for reconsideration. The CRSM has 60 calendar days to make this decision.

The CRSM will then send a letter with its results to the supplier, either to pay the claim or to explain the reasons for the rejection. When the project is complete, Noridian forwards any detected overpayments to CMS, which asks Medicare`s administrative contractor to begin reimbursing the overpayments. At this point, the provider must decide whether or not to initiate the CMS appeal procedure. Let us know if Nexsen Pruet can guide you through this process. Why are suppliers selected for audit? Overall, the main reason suppliers are targeted for an SMRC audit is when CMS data shows that the supplier charges certain codes at outlier rates compared to the national average. The CRMO will then inform the DME MAC of the decision to pay or reject. The MAC DME adapts the claim and a transfer consultation with the results of the adjustment is generated. The supplier has the right to appeal the SMRC`s decision if the application remains denied. If you are a vendor that fits one of the current CDRS project categories, now is a good time to make sure your documentation and coding are up to date. If you have already received an SMRC audit, the best defense begins immediately before the requested recordings are submitted. At this early stage, the focus should be on creating comprehensive and well-organized records, developing clinical arguments regarding the need for care, adding medical and/or expert support for cases, identifying technical issues, and much more. A well-developed initial response can result in the RMHC being resolved without overpayments or with fewer overpayments.

If a claim is rejected because it did not receive any documents requested by the SMRC, the next step is to send the documents to the MAC EMR that issued the application letter for the overpayment. This must be done within 120 calendar days of the claim letter. .