New audit on GIP claims

Categories: Policy.

As many providers will remember, the U.S. Department of Health and Human Services Office of Inspector General issued a report in March 2016 titled, “Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care.” In response to the report, CMS has directed StrategicHealthSolutions, LLC, as the Supplemental Medical Review Contractor, to conduct post-payment review of claims for calendar year 2015 to identify claims for GIP care that may have been improperly paid under the Medicare Part A benefit.

The SMRC will review 65 providers for this post-payment review.

What is a SMRC?

Many providers have asked for clarification about the role of the Supplemental Medical Review Contractor. What follows is some basic information about SMRC.

As the Supplemental Medical Review Contractor (SMRC), StrategicHealthSolutions, LLC has been contracted by CMS Center for Program Integrity to perform and/or provide support for a variety of tasks aimed at lowering the improper payment rates and increasing efficiencies of the medical review functions of the Medicare and Medicaid programs. One of their primary tasks will be conducting nationwide medical review as directed by CMS. The medical review will be performed on Part A, Part B, and DME providers and suppliers to determine whether Medicare claims were billed in compliance with coverage, coding, payment and billing practices.

The selection of topics and time frames to be reviewed is determined by and at the direction of CMS. The focus of the projects may include, but are not limited to 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, professional organizations and First-Look Analysis Tool for Hospital Outlier Monitoring (FATHOM) report and Program for Evaluating Payment Patterns Electronic Report (PEPPER). The SMRC is conducting medical review based on the analysis of national claims data versus data that is limited to a specific jurisdiction as performed by Medicare Administrative Contractors (MACs). Unlike the MACs, the SMRC does not perform claim payment functions.