Home Health & Hospice Week

Use this expert tip to avoid duplicative medical review of claims.

If you’re confused about another Medicare contractor that has joined the alphabet soup of organizations that can conduct medical review of your claims, CMS is clearing it up.

The Centers for Medicare & Medicaid Services contracts with StrategicHealthSolutions to be a Supplemental Medical Review/Specialty Contractor (SMRC), the agency says in a Sept. 30 post on its website. The SMRC conducts nationwide medical review at CMS’s direction to "evaluate medical records and related documents to determine whether Medicare claims were billed in compliance with coverage, coding, payment, and billing practices," CMS says.

Targets: Claims may be chosen for review based on "vulnerabilities identified by CMS internal data analysis, the Comprehensive Error Rate Testing (CERT) program, professional organizations and Federal oversight agencies," CMS continues.

The SMRC will notify CMS "of any identified improper payments and noncompliance with documentation requests," the agency explains. Then "the Medicare Administrative Contractor (MAC) may initiate claim adjustments and/or overpayment recoupment actions through the standard overpayment recovery process."

CMS actually contracted with SHS last year to be the SMRC, reports Washington, D.C.-based law firm Liles Parker. "The contractor has been employing statistical sampling and extrapolation practices, thereby significantly magnifying any projected overpayments identified through the contractor’s efforts," the law firm warns on its website.

Tip: "If you have already been audited by another entity for the same claims, the SMRC will release their audit if you send them proof of previous Complex Medical Review," advises U.S. Re-hab, a division of VGM Group, on its website.