Revenue Cycle

RAC readiness for automated reviews

Recovery Auditor Report, October 6, 2011

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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