decisionhealth Newsletters, Part B News - 2014 Issue 3 (March)
As RACs temporarily fade, new medical review contractor rises up
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Article Overview
This article covers the emergence of CMS’s supplemental medical review contractor (SMRC) program and how it fits into the broader post-payment audit environment. It is relevant to providers, billing staff, compliance teams, and denials management professionals who track audit activity, documentation demands, and the impact of review contractors on claims processing. The article also discusses the general categories of review topics being targeted and the contractor’s relationship to other CMS audit and integrity efforts.
Why This Topic Matters
Healthcare organizations need to understand how CMS review contractors can affect claim payment, record production workload, and denial risk. Awareness of the SMRC program helps practices anticipate audit exposure and prepare for documentation requests and appeal processes.
What You Will Learn
- How CMS uses supplemental medical review contractors in post-payment claim review
- What kinds of claim categories and audit themes may be selected for review
- How documentation requests and record-production costs are handled in the audit process
- What happens after a claim denial under this type of review
- How this review program relates to other CMS audit and integrity efforts
Who Should Read This
- Physician practices
- Billing and coding staff
- Compliance officers
- Revenue cycle managers
- Denials management teams
- Healthcare administrators
Codes Discussed
Code Ranges Discussed
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