Medicare Compliance & Reimbursement

This MAC Is Rejecting Claims Via EDI

If you’ve recently started using the electronic data interchange (EDI) — or even if it’s old hat to you — your payer might be experiencing issues when it comes to processing those EDI claims.

National Government Services (NGS), a Part B Payer, released an email blast notification on Oct. 30 indicating that the October 2013 Quarterly Release included an update that verified eligibility for incoming claims. Unfortunately, the update appears to have caused more issues than it fixed.

“This new method has caused errors such as not recognizing spacing, punctuation, and characters in a beneficiary’s name,” NGS said in the email. “As a result, claims are rejecting.”

If you are one of the unlucky practices impacted by this update, know that CMS has allowed NGS to hold the impacted claims until a resolution is discovered. Once the technical bug is fixed, NGS will do a mass adjustment to reprocess claims. Therefore, you needn’t resubmit those claims to NGS.

Add SMRC To The RACs And Other Audit Organizations

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.

CMS 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.”

For more on SMRC audits, visit www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/SMRC.html.