Q&A: Supplemental medical review contractors

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

A: The SMRC conducts nationwide medical reviews at the direction of CMS. These reviews may be pre- or post-payment, 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.

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: This article originally appeared in the Revenue Cycle Advisor. This question was adapted from the HCPro book The Coder's Guide to Physician Queries by Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP, with contributions from Rose T. Dunn, MBA, RHIA, CPA, CHPS, FACHE. For more information about CERT reports from CMS and the recent vulnerabilities identified, click here. For more information about the denials and audit landscape, read the September/October 2017 edition of the CDI Journal.