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:
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How will RACs review claims for overpayments and underpayments?
- 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; or
- occur when no timely response is received in response to a medical record request letter.
RACs will use complex review in cases where there is a high degree of probability but not certainty that an overpayment exists. Whenever needed for reviews, the RAC may obtain medical records by going onsite to the provider’s location to view/copy the records or by requesting that the provider mail/fax or securely transmit the records to the RAC.
Recovery Audit Contractors
RAC Scopes and Jurisdictions
Where can I learn what issues the RAC is reviewing?
Whose claims can be reviewed by the RAC?
Aren’t RACs focusing on hospital claims?
Do RACs review claims paid by Medicare Advantage Managed Care plans?
How far back can RACs look in reviewing claims?
Will RACs review claims for evaluation and management services?
RAC Review Criteria
How will RACs review claims for overpayments and underpayments?
RAC Recovery Requests
How can I identify a RAC recovery versus a request for refund from other sources?
If I disagree with an RAC's overpayment findings, can I appeal?
Is there limitation on recovery of small overpayments found by the RAC?
Medical Record Review by the RAC
Must I allow the RAC to conduct an on-site review of my medical records?
Planning to Avoid RAC Issues
What should I do to protect my practice from RAC recovery efforts?
