Case Management

Mentor moment: Understanding semi-automated RAC reviews

Case Management Weekly, April 20, 2011

Providers familiar with automated claims reviews and complex claims reviews by recovery audit contractors (RAC) now face another method of overpayment identification—the semi-automated claims review.

Semi-automated review is essentially a hybrid of the automated and complex methods of overpayment identification recognized in the RAC statement of work. CMS divides this new review process into two parts. 

The first involves automated review of claims data to identify billing aberrationswith a high index of suspicion of improper payment.

 “The first part of the new process is essentially the data mining the RACs have done all along using their proprietary systems, and is very similar to automated reviews,” says Kimberly Hoy, JD, CPC, director of Medicare and compliance at HCPro, Inc.

“The only exception being that identified claims only contain possible errors, rather than assumed errors, as in a standard automated review,” she says.

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