Centers for Medicare and Medicaid Services (CMS) MS supplemental medical review contractor (SMRC), StrategicHealthSolutions (Strategic), has a current hospice project. Project Y3P0440 — Hospice, deals with the general inpatient (GIP) level of care. Strategic is conducting 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 project is in response to the Office of Inspector General (OIG) report, “Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care”.
In response to the report, CMS agreed to determine an appropriate number of claims to review for GIP stays that may be billed inappropriately under Medicare coverage requirements. Accordingly, CMS has directed Strategic to conduct the reviews. A sample letter to providers requesting additional documentation can be found here.
Even if not receiving a letter requesting additional documentation, hospice providers should be aware that the documentation being requested by Strategic includes the following:
- Documentation to support a precipitating event for GIP care such as pain control or acute or chronic symptom management that cannot reasonably be provided in other settings
- Documentation to support that interventions tried in the setting prior to GIP admission were unsuccessful
- Documentation to support pain control
- Documentation to support symptom control
Hospices should ensure all GIP documentation contains this information.
Strategic’s website provides some additional information about the project.
Providers should recognize Strategic Health Solutions as the CMS supplemental medical review contractor (SMRC). SMRCs are assigned projects by 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). The SMRC will be performing medical review projects in accordance with CMS regulations, CMS Publication 100-08 (known as the Program Integrity Manual) and other current and future CMS PCG/DMRE initiatives. Current SMRC projects are posted and found here. Additional information about SMRCs can be found on the CMS SMRC webpage.
SOURCE: NAHC Report: Issue #3105, 3/21/2017