Among the plethora of different contractors used by the Centers for Medicare & Medicaid Services (CMS) to administer the Medicare program is the Supplemental Medical Review Contractor, or SMRC. Like the Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs), Unified Program Integrity Contractors (UPICs), and others, the SMRC – of which there is only one at any given time – also audits the claims submitted for reimbursement by Medicare providers and suppliers and issues allegations that providers have received overpayments. Noridian Healthcare Solutions, which is also a MAC, was selected as the SMRC in 2018 and remains the current SMRC.
SMRC audits generally begin with an Additional Documentation Request (ADR), usually in a distinctive green envelope with the Noridian SMRC letterhead or logo. After the provider submits the requested records, the SMRC conducts the review based on the analysis of national claims data, statutory and regulatory coverage, and coding, payment, and billing requirements. The SMRC should eventually issue a Review Results Letter. Providers should be aware that a SMRC review can sometimes last for several months with no intervening correspondence or status updates from the SMRC. Providers who expect, but have not received, a SMRC response should consider carefully checking their Medicare EOBs for activity their MAC may have taken based on the SMRC audit and note any appeal deadlines. Also, providers should be aware that the SMRC is a regional contractor who is allowed to conduct audits nationwide and thus may misunderstand local rules, state laws, or LCDs. SMRC audit findings should generally be carefully scrutinized.
SMRC audit findings also have an additional appeal mechanism available to them. Where the SMRC denies claims, the provider generally has a right to appeal the findings directly to the SMRC and can sometimes request a discussion and education session directly with the SMRC. If the SMRC denies the appeal, it will refer the case to the provider’s local MAC to collect the alleged overpayment or to other government agencies for further action. Where the MAC demands that the provider return an overpayment based on the SMRC’s findings, that demand is subject to the standard Medicare claims appeal process.