Is SMRC cherry-picking old claims?

Friday, June 6, 2014

YARMOUTH, Maine – StrategicHealthSolutions is digging deep in its latest round of post-pay reviews, industry stakeholders say: diabetes supply claims from 2011-2012.

“We had to go to the pallets in the warehouse and find these,” said Marcus Suess, CEO of All-States Medical Supply in Fletcher, N.C. “We’ve been electronic for a while but we boxed up the EOBs—we’re too busy to scan everything.”

Medicare contracted with the Omaha, Neb.-based StrategicHealthSolutions to serve as a Medicare supplemental medical review contractor (SMRC) in 2012.

Stakeholders suspect the contractor thinks older claims are more likely to contain errors.

“The bad thing is they are picking on old dates of service where providers might not have been as careful,” said Kelly Wolfe, CEO of Regency Billing and Consulting, who has heard from clients in Jurisdictions B, C and D about the documentation requests from StrategicHealthSolutions. “I predict some providers might be lacking in the documentation as to whether the refill request was called in or the request was made in person.”

One of the biggest reasons diabetes claims get denied is for overutilization. Medicare guidelines allow testing frequency of once per per day for non-insulin patients, three times per day for insulin-dependent patients and six times per day for pump users. Provider Dan Gooch, who got hit with 100 documentation requests at once, said his claims don’t fall into that category.

“They are both insulin and non-insulin dependent with some checking their blood sugar as little as once per day,” said Gooch, owner of Pal-Med in Columbia, S.C. “I don’t understand their logic.”

When it comes to auditors, Suess doesn’t trust in logic. He’staking the added precaution of sending along copies of the local coverage determinations (LCDs) that were in effect in 2011 and 2012.

“We don’t believe they will follow what we show them,” he said. “We have zero faith in the process.”