Revenue Cycle

Q&A: RAC automated reviews

Recovery Auditor Report, January 8, 2009

Q: Under what circumstances can a RAC make a finding that an overpayment or underpayment exists without requesting medical records?

A: RACs may use automated review (where no medical record is involved in the review) only in situations where there is certainty that the claim contains an overpayment. Automated review must meet one of the following criteria:

  • Have clear policy that serves as the basis for the overpayment (“clear policy” means a statute, regulation, National Coverage Determination, coverage provision in an interpretive manual, or Local Coverage Determination that specifies the circumstances under which a service will always be considered an overpayment)
  • Be based on a medically unbelievable service
  • Occur when no timely response is received in response to a medical record request letter

Editor’s note: This Q&A was excerpted from the CMS Web site. For additional RAC Q&A, click here.  

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