SMRC Audits
Medicare Compliance Attorneys Experienced in SMRC Audit Defense
SMRC Audits Team Lead
Former DOJ Attorney
SMRC Audits Team Lead
SMRC Audits Consultant
Former HHS-OIG Assistant Special Agent-in-Charge
The Centers for Medicare & Medicaid Services (CMS) Supplemental Medical Review Contractor (SMRC) is one of several private entities tasked to conduct nationwide medical reviews of Medicare billing compliance. In CMS’s words, the SMRC’s role is “to help lower improper payment rates and protect the Medicare Trust Fund.”
The current SMRC is Noridian Healthcare Solutions, LLC. If your business or practice has received an Additional Document Request (ADR) letter from Noridian, you are facing an SMRC audit. You will need to plan and execute your response carefully, as SMRC audits can (and frequently do) lead to claim adjustments, claim denials, recoupments, and other adverse consequences.
Experienced Defense Counsel for Healthcare Entities Facing SMRC Audits
At Oberheiden P.C., we serve as experienced defense counsel for healthcare providers, durable medical equipment (DME) companies, and other entities that are facing SMRC audits. Our lawyers and consultants have extensive experience advising clients in connection with all types of Medicare audits, including those conducted by Noridian, Medicare Administrative Contractor (MAC), Recovery Audit Contractors (RACs), Unified Program Integrity Contractors (UPICs), and others.
If your business or practice faces an SMRC audit by Noridian, our team can guide you step-by-step. We can make sure you are as prepared as possible through comprehensive error rate testing, and we can deal with Noridian’s auditors on your behalf. We can challenge the flawed methodologies and assumptions of the certified professional medical auditor, ensure that they apply the correct Medicare billing regulations, and help you take responsive action after the audit as necessary.
Common Issues During SMRC Audits
What are some of the key concerns for healthcare entities facing SMRC audits? When assessing Medicare billing compliance, Noridian looks for two key things: (i) evidence of non-compliance and (ii) insufficient evidence of compliance.
Both can be equally consequential for Medicare-participating businesses and providers. Not only will Noridian refer clear overpayments to MACs for appropriate action (i.e., recoupment), but when in doubt, it will err on the side of noncompliance. Thus, if a business or provider’s on-hand records do not clearly justify an amount billed to Medicare, the billing will almost certainly be questioned—and at this point, avoiding recoupment will be an uphill battle even if the billing is compliant.
With this in mind, some of the most common issues during SMRC audits include:
- Insufficient documentation and coverage requirements of medical necessity
- Insufficient documentation supporting a more expensive service over a less expensive alternative
- Insufficient documentation of the quality of the services provided
- Insufficient documentation of the effectiveness of treatment
- Billing and coding errors resulting from ineffective Medicare billing compliance protocols
- Billing and coding errors resulting from individuals’ oversights or negligence
- Double-billing, unbundling, and whether claims follow coverage (or inability to demonstrate that such mistakes have not been made)
Again, these are just examples of numerous possibilities. Facing an SMRC audit is a high-risk matter, and presenting an effective defense is a time and resource-intensive process. Ideally, healthcare providers and other entities will have policies and procedures in place to guide their initial response. But, in all cases, a prompt and proactive response is critical, and those facing scrutiny from Noridian will need to work closely with experienced Medicare compliance counsel to ensure that they do not face unnecessary consequences.
Put our highly experienced team on your side
Dr. Nick Oberheiden
Founder
Attorney-at-Law
Lynette S. Byrd
Former DOJ Trial Attorney
Partner
Brian J. Kuester
Former U.S. Attorney
Hon. Kevin McCarthy
55th Speaker, U.S. House of Representatives (ret.)
Government Consultant
Mike Pompeo
Of Counsel
Former U.S. Secretary of State
John W. Sellers
Former Senior DOJ Trial Attorney
Linda Julin McNamara
Federal Appeals Attorney
Nicholas B. Johnson
Former Prosecutor
Roger Bach
Former Special Agent (DOJ)
Chris J. Quick
Former Special Agent (FBI & IRS-CI)
Michael S. Koslow
Former Supervisory Special Agent (DOD-OIG)
Ray Yuen
Former Supervisory Special Agent (FBI)
Our Approach to the SMRC Audit Process
When representing healthcare providers, DME companies, and other businesses and facilities in SMRC audits, we take a comprehensive and detail-oriented approach focused on ensuring that our clients do not unnecessarily face recoupments or other penalties. This is a very real risk, and entities that do not manage the audit process regularly face inordinate financial consequences and the need to file an appeal.
To help our clients avoid these outcomes, we take steps including:
1. Carefully Reviewing Noridian’s ADR Letter
The first step we take is to carefully review Noridian’s ADR letter. While these letters are typically uniform in terms of their basic contents and structure, it is still important to look for any unexpected concerns that could present issues during the audit process. At this stage, however, the primary focus will generally be on ensuring that the recipient knows what documents it needs to submit in response to the ARD to avoid being deemed non-compliant.
2. Collecting All Necessary Medical Records, Billing Records, and Supporting Documentation
Next, we assist our clients with identifying and collecting all relevant records, including your own medical record packet, physician documentation detailing the prior course of treatment, billing records, and supporting documentation. Failing to provide any requested documents will raise red flags and almost certainly lead to additional scrutiny.
3. Reviewing These Records Prior to Disclosure
Before providing any records to Noridian, it is critical to review them for purposes of assessing their compliance implications. At this stage, providers and other entities can (and should) protect themselves by making sure they know what (if anything) Noridian’s auditors are going to find before they find it.
4. Proactively Addressing Any Medicare Billing Compliance Concerns
If the records requested in an ADR present any Medicare billing compliance concerns, the SMRC audit target will want to address these concerns proactively. What this means will depend on the circumstances involved, and our attorneys and consultants work closely with our clients at this stage to ensure they are making informed decisions.
5. Maintaining Contact with Noridian During the Review Process
After assisting with submitting our clients’ responsive documents, we remain in contact with Noridian throughout its review process. Based on our knowledge of the Medicare billing regulations, SMRC audit procedures, and our client’s records, we can focus on ensuring that auditors’ errors and oversights do not lead to flawed determinations at this stage.
6. Reviewing and Responding to Noridian’s Review Results Letter
After completing its review, Noridian will issue a Review Results Letter. Our attorneys will carefully review this letter, assess its implications, and help our clients make informed decisions about their next steps. If the letter contains unjustified adverse findings, we will typically continue working directly with the SMRC at this stage, including requesting a “Discussion and Education” session if necessary.
7. Filing an Appeal and/or Taking Other Responsive Action as Necessary
After the SMRC audit process is complete, we also assist our clients with taking any other necessary responsive action. This can range from filing an appeal with the SMRC or a MAC to updating the entity’s Medicare billing compliance protocols or preparing for a potential healthcare fraud investigation.
FAQs: Avoiding Claim Adjustments and Recoupments During an SMRC Audit
What Should I Do if I Received an Additional Document Request (ADR) from Noridian?
If you received an ADR letter from Noridian, your Medicare-participating business or practice faces an SMRC audit. These audits target Medicare overpayments, and they can lead to substantial recoupments and other penalties. As a result, upon receiving an ADR letter, it is important to engage experienced counsel to help you prepare for the audit, including additional documentation request, as soon as possible.
Why was My Practice Selected for an SMRC Audit?
In most cases, SMRC audits target specific Medicare billing compliance areas, which CMS calls “projects.” If your business or practice bills Medicare in one of CMS’s current “project” areas, there is a good chance that you will face an SMRC audit. With that said, Noridian (CMS’s current SMRC) also targets providers for other reasons, and SMRC audits can also broadly target Medicare billing compliance in some cases.
What Types of Medicare Billings Does an SMRC Audit Cover?
The SMRC, which is currently Noridian, has the authority to conduct billing compliance audits under Medicare Part A, Medicare Part B, and Medicare DMEPOS. Within each of these three program areas, SMRC audits can target all areas of Medicare billing compliance.
What Are the Possible Outcomes of an SMRC Audit?
The possible outcomes of an SMRC audit range widely. Of course, the best-case scenario is to resolve the audit with a confirmation of compliance and with no recoupment liability. However, SMRC audits frequently lead to recoupments and other financial consequences (i.e., claim adjustments and denials), and CMS’s SMRC also has the authority to refer suspected instances of Medicare fraud to MACs or federal authorities for further inquiry.
Do I Need to Hire a Lawyer for an SMRC Audit?
Due to the complexity of the SMRC audit process and the significant financial risks involved, providers and businesses facing these audits should engage experienced legal counsel promptly. A lawyer familiar with the Medicare billing regulations and SMRC audit processes will be able to effectively oversee the process and help steer it toward a favorable resolution.
Discuss Your SMRC Audit with a Senior Medicare Compliance Attorney at Oberheiden P.C.
Is your Medicare-participating business or practice facing an SMRC audit? If so, our lawyers and consultants can manage the process on your behalf and help you avoid unnecessary adverse consequences. To learn more in a complimentary initial consultation, please call 888-680-1745 or request an appointment with a senior Medicare compliance attorney at Oberheiden P.C. today.
