Knowledge Base Article

Did You Know?

Noridian Healthcare Solutions, LLC (Noridian) is the current Supplemental Medical Review Contractor (SMRC). “With CMS directed topic selections and timeframes, Noridian conducts nationwide medical reviews (Part A, Part B, and DME), in accordance with all applicable statutes, laws, regulations, national and local coverage determination policies, and coding guidance, to determine whether Medicare claims have been billed in compliance with coverage, coding, payment, and billing practices.”

Reviews are assigned to the SMRC based on analysis of national claims data issues identified by other Federal agencies (i.e., OIG, Government Accountability Office (GAO), the Comprehensive Error Rate Testing Program (CERT), and Program for Evaluating Payment Patterns Electronic Report (PEPPER)).

Why It Matters?

As of August 15, 2023, the SMRC has thirteen current projects. Examples of current projects includes hyperbaric oxygen of lower extremities diabetic wounds, hospice general inpatient (GIP) level of care, cryosurgery of the prostate, and Mohs surgery.

Also, as of August 15, 2023, Noridian has completed sixty projects since being awarded the $227 million SMRC contract by CMS in 2018. Error rates for their completed projects range from 1% to 98%.

The 1% error rate was for a sample of claims reviewed related to the 20% add-on payment for COVID-19 that was in place during the COVID-19 Public Health Emergency. The 98% error rate was for a review of claims for Medicare Part B emergency ambulance services.

In July of this year, in addition to reporting an error rate for the reviewed claims, Noridian began reporting an error rate for the number of claims denied due to no response to an Additional Documentation Request (ADR). To date, SMRC medical review findings that include the no response error rate, includes:

Project 01-080: Vitamin B12 with Modifier 25 Findings of Medical Review

Error Rate for Reviewed Claims: 43%

No Response to ADR Denials: 39%

Results Published July 18, 2023

https://noridiansmrc.com/completed-projects/01-080/

Project 01-081: Outpatient Dental Services CPT 41899 Findings of Medical Review

Error Rate for Reviewed Claims: 95%

No Response to ADR: 20%

Results Published July 18, 2023

https://noridiansmrc.com/completed-projects/01-081/

Project 01-093: Overlapping Claims – Hospital Transfers During the PHE Findings of Medical Review

Error Rate for Reviewed Claims: 12%

No Response to ADR: 8%

Results Published July 18, 2023

https://noridiansmrc.com/completed-projects/01-093/

Project 01-050: Podiatry Findings of Medical Review

Error Rate for Reviewed Claims: 45%

No Response to ADR Denials: 29%

Published August 8, 2023

https://noridiansmrc.com/completed-projects/01-050/

Project 01-072: Neurostimulator Implantation Findings of Medical Review

Error Rate for Reviewed Claims: 39%

No Response to ADR Denials: 23%

Results Published August 15, 2023

https://noridiansmrc.com/completed-projects/01-072/

Noridian notes they must notify CMS of identified improper payments and noncompliance with documentation requests. They will initiate claims adjustments and/or overpayment recoupment by the standard overpayment recovery process.

What Can I Do?

First and foremost, make sure you have a process to receive and respond to ADR requests from the SMRC and other review contractors (i.e., CERT).

If a claim is denied for no receipt of documentation, you can complete the following steps posted to the Noridian Jurisdiction E (JE) MAC website:

SMRC Reviews Denied for No Documentation

“When a claim is denied for no receipt of documentation requested by the SMRC, the next step is to submit the documentation to the MAC that issued the demand letter for the overpayment. This must occur within 120 calendar days of the demand letter.

This situation is considered a reopening and the MAC will send the submitted documentation to the SMRC for a re-review decision. The SMRC has up to 60 calendar days to make this decision. The SMRC will then mail a letter to the supplier with their findings, either to pay the claim or they will outline the reasons for denial.

The SMRC will next notify the MAC of the payment or denial decision. The MAC will adjust the claim and a remittance advice with the adjustment results will be generated. The provider has the right to appeal the SMRC decision, if the claim remains denied.

Based on the timeframes and steps listed above, please call the MAC about the status of the SMRC re-review only after at least 140 days have passed from when documentation was sent.”

Last, become familiar with information available on the SMRC website (https://noridiansmrc.com/).