In August of this year, Noridian Healthcare Solutions, LLC (Noridian) was selected by CMS to conduct nationwide medical reviews as directed by CMS. 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. As part of that effort, CMS retained Noridian as the Supplemental Medical Review Contractor (SMRC).
Reviews are not determined by Noridian, instead, they are assigned through CMS formal notifications and focus on analysis of national claims data issues identified by Federal agencies, such as the Office of Inspector General (OIG), Government Accountability Office (GAO), CMS internal data analysis, the Comprehensive Error Rate Testing (CERT) program, and professional organizations, and/or analysis reports such as First-Look Analysis Tool for Hospital Outlier Monitoring (FATHOM) report, and Program for Evaluating Payment Patterns Electronic Report (PEPPER).
Since the contract award, Noridian has been quiet...until now. As of last week, DMEPOS suppliers have begun receiving audit notifications from the SMRC. The letters indicate that the reason for selection is a direct result of the OIG report A-04-17-04056 from June 2018. Suppliers are required to submit documentation to support the selected claims chosen for review. Given the OIG's recent notification to suppliers that requires they self-audit PAP supplies provided in the last six years, the SMRC's involvement in this project comes as no surprise.
The good news is that you don't have to navigate this process alone. If you receive an ADR request from the SMRC, let The van Halem Group help you navigate this process. Our team of clinical experts can review your files and provide valuable feedback. In addition, the experts at vHG will respond to the audit on your behalf and provide guidance during the appeals process, as needed.
If you haven't received a request from a CMS audit contractor, but would like assurance that your documentation meets coverage requirements, let our team give that to you! Our experts can conduct a proactive desk audit that includes a comprehensive clinical, coding, and technical review, an Executive Summary of the audit results, and a follow-up education and training session with appropriate staff members. Be audit ready and prepared. Surprises can be fun, but not during an audit from a Federal contractor!
You don't have to go through this process alone. Our team of experts are here for you. For more information visit our website and contact us today!