CMS contracted with StrategicHealthSolutions in 2013, to serve as the nationwide SMRC, and to help the agency lower improper payment rates and increase efficiencies in medical reviews. The SMRC’s primary responsibility is to conduct medical reviews on Medicare Part A, Part B and DME providers and suppliers throughout the US; specifically focusing on medical records and documents that help CMS determine whether Medicare claims are billed in compliance with all of the current coverage, coding, payment and billing practices. The focus of these reviews may include vulnerabilities identified by CMS’ internal data analysis, the Comprehensive Error Rate Testing (CERT) program, professional organizations or other Federal oversight agencies. The SMRC must notify CMS of any identified improper payments and noncompliance with documentation requests.
The SMRC medical reviews are conducted in accordance with the CMS Program Integrity Manual and other current and future CMS Provider Compliance Group and CMS Division of Medical Review and Education initiatives. Providers and suppliers much furnish proper documentation upon SMRC request, in accordance with the Social Security Act (SSA), § 1833. The SMRC request also complies with the Health Insurance Portability and Accountability Act (HIPAA) privacy rule, which allows release of information for treatment, payment and healthcare operations.