Many practices get chart requests. There are a few entities that are not as well-known as others, but one of them is currently active in the eye-care world now.
Let’s examine some things about the new kid on the block: the Supplemental Medical Review/Specialty Contractor.
Q What is the SMRC program?
A The Centers for Medicare & Medicaid Services does many things to ensure proper claims payment. Sometimes it hires outside entities to assist with this effort. The SMRC program is one such entity. Though they’re similar to the Recovery Auditors we hear so much about, SMRCs have a national scope and aren’t restricted to one region, specialty or service type. CMS notes that an SMRC will “provide support for a variety of tasks aimed at lowering the improper payment rates and increasing efficiencies of the medical review functions of the Medicare and Medicaid programs.” CMS also states that the “focus of the reviews may include, but is not limited to, vulnerabilities identified by CMS internal data analysis, the Comprehensive Error Rate Testing program, professional organizations and Federal oversight agencies … [and that] providers/suppliers must provide documentation upon request.”
Q Who is the current SMRC organization?
A In September 2012, CMS selected StrategicHealthSolutions, based in Omaha, Nebraska, as an SMRC. StrategicHealthSolutions lays out its tasks on its website: “[One] of the primary tasks will be conducting nationwide medical review as directed by CMS. The medical review will be performed on Part A, Part B, and DME providers and suppliers to determine whether Medicare claims were billed in compliance with coverage, coding, payment and billing practices. The selection of topics and time frames to be reviewed is determined by and at the direction of CMS. The SMRC is assigned each project through Technical Direction Letters (TDL) issued by CMS.” It notes that one of its advantages over recovery auditors is that it conducts “medical review based on the analysis of national claims data versus that limited to a specific jurisdiction.”
Q How does the SMRC select who is the subject of a review, and how will I know if I am under review by StrategicHealthSolutions?
A While CMS must direct the topics, some reviews are truly random—others are data-driven. The notice of a review will come in the form of a letter addressed to the provider/practice, and StrategicHealthSolutions is careful to note its authority to do so. The letter tells the practice what the SMRC is, what the practice must do and gives the time frame within which to respond. It also notes that there is not to be any reimbursement for supplying the records to the SMRC. Practices are solely responsible for the costs, even if that practice uses a copying service.
Q Once I turn in the records, how long will I have to wait for a response?
A Generally, responses from the SMRC take about three months. The results letter identifies for the provider whatever does not pass muster. If a practice has claims that have no issues, the SMRC letter notes that “no further action is needed” or something similar for those particular records.
Q What topics is the SMRC currently reviewing?
A There are currently two active SMRC “projects”:
• Project Y3P0225 – Blepharoplasty and other related facial procedures.
• Project Y3P0239 – Ophthalmology Services.
The Blepharoplasty project is focused on medical support for functional eyelid surgery. Ptosis surgery is included. The Ophthalmology Services project has a wide scope and includes support for cataract surgery, eye exams, diagnostic testing and a few others. There is a third project related to Lucentis, but it is wrapping up.
Q What happens if I sent in documentation that didn’t pass?
A The SMRC gives a provider an “ … opportunity for a Discussion/Education Period … The Review Results Letter will inform providers if the project is eligible for a Discussion/Education Period [which] is intended to allow for the review of specific claim denials, deliver rationale and education for the determination(s), and provide information on how the denial can be avoided in the future. Additionally, if a provider determines there is additional information and/or documentation relevant to supporting payment of the denied claim(s), the provider may submit the additional information and/or documentation. All Discussion/Education Period requests must be in writing.”2 If you’re allowed this opportunity for discussion, you have 30 days from the date of the letter to respond. One of the options is to have a teleconference, but that’s not always required.
It’s possible that the SMRC might alter its decision based on additional information you send during this period. If the SMRC still feels you have not met the required standard, CMS states that “StrategicHealthSolutions, LLC has a responsibility to notify CMS of any identified improper payments and noncompliance with documentation requests.” CMS does this most often by notifying your Medicare Administrative Contractor. The MAC may initiate claim adjustments and/or overpayment recoupment actions through the standard overpayment recovery process.
Q What happens if I miss the deadline?
A Don’t! Anything received after 30 days is considered invalid by the SMRC, so be sure and send via an appropriate method with delivery tracking of some sort.
Q What else should I be aware of?
A Be sure the person opening the mail in your office knows what StrategicHealthSolutions is and how important it is to get the letter to you right away. Also, don’t assume the person reviewing your documents for the SMRC will know, for example, that optical coherence tomography images are in color if you send them in black-and-white. You don’t know who the reviewer will be or their sophistication relating to eye care. Make your best effort the first time, which includes sending a written summary in addition to your records if you feel this will help give the reviewer a better clinical picture.
Mr. Larson is a senior consultant at the Corcoran Consulting Group. Contact him at firstname.lastname@example.org.
1. https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/medical-review/smrc.html. Accessed 17 August, 2017.
2. https://strategichs.com/smrc/discussion-period-or-education-session/. Accessed 17 August, 2017.