RAC readiness for automated reviews
Recovery Auditor Report, October 6, 2011
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While automated reviews do not require medical record (MR) review, they are the most difficult to prevent because they cover a large number of clinical areas, cross multiple providers, and look at many discrete billing units. Front-end prevention and preparation will require expertise and participation from a broad set of clinical departments. That is the reason we have focused on structure, process, and people in previous chapters. By creating a system to engage the entire organization in billing compliance, risk areas can be minimized. For example, by educating clinical departments on the RAC-approved issues within their span of control, the specific clinical department director (CDD) takes ownership of the issue as a performance improvement (PI) project.
Even if a single claim amount is small, consider the amount at risk for the entire group of related claims. Although a single claim may be a low dollar amount compared to some of the complex reviewed cases, when you consider the risk to the entire claim group or for an automated review that is converted to a complex review, it is important that you focus risk assessment on both automated and complex reviews.
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