The Department of Health and Human Services, Centers for Medicare and Medicaid Services has a requirement for Supplemental Medical Review Contractor SMRC.

The Centers for Medicare & Medicaid Services (CMS) is the Federal agency that administers the Medicare and Medicaid programs. A top priority for CMS is reducing improper payments in the Medicare Fee-for-Service (FFS) program. To protect the Medicare Trust Fund, CMS must prevent improper payments that result in a loss of taxpayer dollars. Preventing improper payments requires the active involvement of multiple components in CMS and effective coordination with its partners, including various Medicare Contractors and providers/suppliers. CMS evaluates medical records and related documents to determine whether Medicare claims were billed in compliance with statutory, regulatory and sub- regulatory coverage, coding, payment, and billing rules. Paid claims that do not comply with Medicare’s coverage, coding, payment and billing rules are considered improper payments. Analyses of Medicare Parts A/B/DMEPOS claims data is one way to identify that Medicare may have paid claims improperly. Providers and suppliers may submit claims to various Medicare contractors under multiple provider numbers. In addition, some potential improper payments can only be identified when a provider’s Medicare claims data is compared to what that provider billed to a Medicaid agency or other public or private payer. These improperly paid claims could result in significant losses to the Medicare Trust Fund.

The Contractor claim reviews require, at a minimum, the clinical evaluation of medical records and related documents to determine whether Medicare claims were billed and paid in compliance with Medicare’s coding, coverage, billing and payment requirements. Statutory authority for the MR programs is found in Sections 1833(e) and 1862(a) of the Social Security Act (the Act).

The following is a high-level summary of the key task areas for which CMS is seeking fixed-price recommendations. Respondents should provide pricing input for each task area individually, as well as any recommended bundled or hybrid pricing approaches.

• Task 1: Medical Review for Improper Payments
  • Conduct medical record reviews to identify improper Medicare payments. Includes claim selection, ADR letter issuance, medical record receipt and review, determination issuance, and re-review workload. Carryover costs (labor hours for original claim review, D&E sessions, and re-review workload) shall be tracked separately.
• Task 2: Medical Review for Program Integrity
  • Ad hoc medical record review projects directed by CMS for program integrity purposes. Includes project kickoff meetings, claim review, and reporting.
• Task 3: Discussion and Education (D&E) Sessions
  • Conduct educational outreach with providers/suppliers regarding medical review findings and Medicare coverage policies.
• Task 4: Reporting and Performance Metrics
  • Prepare and submit Monthly Status Reports (MSR) by the 15th of each month, including:
    •  Total medical reviews requested and completed by project title
    •  Reviews completed by state and provider/supplier number
    •  Reviews not completed within established time standards
    •  Performance metrics, challenges, and proposed actions
    •  Tracking reports in Microsoft Excel format
• Task 5: Annual Performance Assessment (APA) Support
  • Support CMS in conducting the Annual Performance Assessment, including site visits and evaluation of:
    • Medical Review Process Flow and Response Time
    • Data Collection, Integration, and Reporting
    • Medical Reviewer Credentials and Training
    • Quality Control (Interrater Reliability – IRR)
    • Provider/Supplier Communication
• Task 6: Quality Control Plan (QCP)
  • Develop and maintain a Quality Control Plan within 14 days of award, including QA procedures, personnel responsibilities, frequency of QA functions, and policy dissemination processes.
• Task 7: IT Systems Setup and Maintenance
  • Develop and maintain IT Systems Project Plan, including:
    • Hardware, software, and telecommunications identification
    • CMS system access and security clearance
    • Weekly data backup capability
    • Joint Operation Agreements (JOAs) and Data Use Agreements
• Task 8: Start-Up / Ramp-Up Activities
  • Develop and execute a Start-Up Project Plan within 10 days of kick-off, operationalizing all SOW tasks within 90 calendar days of contract award.
• Task 9: Record Management and Work Tracking Dashboard
  • Develop and maintain a dashboard tracking:
    • Work days on hand by project
    • Claims selected, reviewed, and re-reviewed
    • ADR letters sent and records received
    • Overpayment recoupment tracking
    • Statistical extrapolation and data analysis activities
• Task 10: Website Development and Ongoing Maintenance
  • Develop and maintain a CMS-approved public-facing website including project descriptions, ADR letter examples, hot topics, and D&E period information.
• Task 11: ALJ Hearing Support
  • Actively participate in Administrative Law Judge (ALJ) hearings (minimum 10 per month), including:
    • Reviewing Notices of Hearing (NOH)
    • Preparing case documentation
    • Assigning physicians for party/participant/witness roles
    • Coordinating with AdQIC and other CMS contractors
• Optional Task 1: Fraud Referral Support
  • Support CMS in referring potential fraud cases to appropriate investigative bodies.
• Optional Task 2: Public Portal Development
  • Develop and maintain a public-facing portal as directed by CMS.
• Optional Task 3: Ad-Hoc Innovation Projects
  • Perform ad hoc innovation projects as directed by CMS.
• Optional Task 4: Statistical Extrapolation of Overpayment
  • Conduct statistical extrapolation analyses, including methodology development, sampling, and reporting.
• Optional Task 5: Recalculation of Statistical Extrapolation
  • Perform recalculations of prior statistical extrapolations, including rationale documentation and revised reporting.