Strategic Health Solutions—Sound Familiar? Keep Reading

Posted on in Billing/Reimbursement

By Ronda Buhrmester, VGM Reimbursement Team

Strategic Health Solutions (SHS) is a supplemental medical review contractor hired by CMS. When you go to their website and click on “Contracts” then “SMRC,” there is a tagline in large font that reads, “Protecting the Medicare Trust Fund.” I chuckle at this because here we have another specialty review contractor that is being paid by CMS to perform audits and “protect the Medicare Trust Fund.” I mean isn’t this what we are all trying to do already? Does CMS need to pay another contractor to constantly find these so-called errors? We have all seen the error rates continually remain in the 70, 80, 90 percent range. I think this means the system is broken and has flaws. CMS needs to take another look at these error rates, try to find ways to fix the broken system and stop pointing fingers at suppliers who are trying to protect the Medicare trust fund.

A little history. SHS is a contractor that performs medical reviews of Medicare Part A, Part B and DME suppliers throughout the U.S. CMS presented a five-year contract that started in January 2013. The reviews are being performed to determine whether Medicare claims were billed in compliance with coverage, coding, payment and billing practices. CMS determines the selection of topics and time frames to be reviewed with issues identified by the Office of Inspector General, Government Accountability Office, Comprehensive Error Rate Testing program, CMS internal data analysis and a few other reporting factors.

While SHS has been performing reviews for Part A and B, I have been keeping my eye on the DME portion for a few years now. SHS was initially contracted to look at the power mobility devises (PMDs) in the states that did not have the prior authorization demonstration project. The next review that occurred was on the vacuum erection device (VED). (The VED is no longer a covered item under Medicare guidelines.) Diabetic test strips were also one of the SHS reviews that is now completed. The suppliers who received the Additional Documentation Request (ADR) letter for diabetic test strips had to submit information on 100 claims from the year 2011. Even though this review came after the diabetes product became a national competitive bid item, CMS still felt the need to perform the review.

Medical reviews, or current projects as they’re called, are occurring on oxygen equipment, CPAP devices and nebulizer equipment, all of which started in September 2015.

If you are looking for another talking point when speaking to your members of Congress, here it is: Below are statistics for oxygen, CPAP and nebulizer equipment according to the Medicare FFS Improper Payments Report:

Share with your members of Congress the ridiculously small percentage of the overall Medicare FFS payment rate. Let them know the issues you are dealing with on a day-to-day basis. And, now you have to deal with another auditing contractor. Tell your members of Congress the system is broken, and the finger needs to stop pointing at the DME supplier who is trying to add quality of life to patients by keeping them at home with quality home medical equipment. Otherwise, the patients will end up in the hospitals and nursing home facilities.

Now let’s review the ADR letter. I am aware that many of you are already familiar with the ADR letter because I have received your telephone calls and emails. The letter states you have 45 days from the date of the notice to respond to the request and may have anywhere from 30-40 claims. If you need an extension, don’t be afraid to ask for one. I have heard on some cases a 15-day extension has been allowed. The person in your office who distributes the mail needs be aware of SHS and to get the letter to the correct person in your office immediately — the compliance officer, billing manager, general manager, owner, etc. Here are some helpful tips once you have read the letter and know what SHS is asking for:

  • Know the due date.
  • Start collecting the data.
  • Keep a spreadsheet and check for duplicates.
  • Make sure medical records are signed and dated and are the correct copies (and are date stamped received).
  • Put the claims in order based on the request in the letter.
  • Check for any previous audits on the same patient, the same HCPCS code, for same date of service. If such an audit exists, include the favorable letter.
  • Include a table of contents.
  • Number the pages to keep your document organized, e.g., 1 of 20, 2 of 20, etc.
  • Review the information before it’s mailed (checks and balances).
  • Copy everything you send so you know exactly what SHS received.
  • We suggest “snail” mailing to be sure SHS actually receives everything.
  • Get a confirmation of delivery.

Remember: More isn’t always better. Send only the information requested.

If you haven’t received a letter from SHS, be prepared as it may be coming your way. SHS haven’t listed its “potential projects,” but I imagine we can take a good guess. Share this information with your staff, referrals and patients to keep them involved. And, don’t forget your congressional representatives.

In summary, when you receive a referral for any type of equipment, try to get as much documentation up front as possible. You need to make sure the coverage criteria has been met and all the checks and balances have taken place. Don’t let any equipment out of your store until you are absolutely sure you have the correct information. The “good ole days” are gone. You need to make sure you get paid and keep the money for the services you provide. Learn to say NO or pay cash!

Get more great advice like this at Mission Possible Mobility and Respiratory Reimbursement Training, located in five cities around the country. Contact me if you have questions. Ronda Buhrmester, CRT - 888-665-6518, [email protected]

To receive assistance with the audits, contact The van Halem Group, a division of VGM Group, Inc. The van Halem Group provides audit and compliance support solutions to help navigate the complex regulatory issues related to submitting claims, responding to audits and filing appeals while avoiding violations of federal and state laws as well as other payer policies and requirements. VGM members receive a 15 percent discount. 

Contact the van Halem Group at 404.343.1815 or [email protected]. Visit their website for more information,

Here are links you may find helpful.

Supplemental Medical Review Contractor

Completed projects
Power Mobility Devices
DME Part 2 Provider
Male Vacuum Erection Devices (VED)
Diabetic Test Strips

Current Projects
Nebulizer ADR
Oxygen ADR
Oxygen and Oxygen Equipment
Nebulizer Equipment and Related Medications and Supplies