Semi-automated reviews, a new weapon that recovery audit contractors added to their arsenal last year, extends RACs' ability to recoup claims from hospitals and other providers, says Elizabeth Lamkin, CEO of Pace Healthcare Consulting in Hilton Head, S.C.
The new category is a hybrid of automated reviews, in which RACs recoup payments based only on electronic reviews of claims data, and complex reviews, where they have to delve into medical records to prove their case.
Semi-automated review starts with an automated review of claims data to identify claims that have a high probability of being improper payments, but no certainty yet. These claims now require a complex review of the medical record. The RAC then requests the documentation, citing the automated review rather than an approved issue posted on its website, as it does for complex reviews.
"We already knew that automated reviews could turn into a complex review," Ms. Lamkin says. "Now they’ve formalized it." She says the semi-automated reviews give RACs more freedom to find new issues to delve into. "RACs' can extend their reach by scanning unlimited numbers of records looking for vulnerabilities," she says.
"This is just the beginning of RACs' expansion into payment issues," Ms. Lamkin adds. She predicts that another upcoming area of expansion will be matching RAC denials of a hospital bill to the physician's claim that goes with that service and denying that payment as well. So far, RACs have done this very infrequently, because RACs work through fiscal intermediaries that pay the claims, and physicians have different fiscal intermediaries than hospitals. Now, however, CMS is consolidating these agencies so that physician and hospital payments are under one roof, she says.
Learn more about Pace Healthcare Consulting.
Related Articles on expansions of RAC activities.
RACs' Semi-Automated Review Explained
CMS Will Encourage RACs to Extrapolate Overpayments
National RAC Program Has Collected $313M Since Launch
The new category is a hybrid of automated reviews, in which RACs recoup payments based only on electronic reviews of claims data, and complex reviews, where they have to delve into medical records to prove their case.
Semi-automated review starts with an automated review of claims data to identify claims that have a high probability of being improper payments, but no certainty yet. These claims now require a complex review of the medical record. The RAC then requests the documentation, citing the automated review rather than an approved issue posted on its website, as it does for complex reviews.
"We already knew that automated reviews could turn into a complex review," Ms. Lamkin says. "Now they’ve formalized it." She says the semi-automated reviews give RACs more freedom to find new issues to delve into. "RACs' can extend their reach by scanning unlimited numbers of records looking for vulnerabilities," she says.
"This is just the beginning of RACs' expansion into payment issues," Ms. Lamkin adds. She predicts that another upcoming area of expansion will be matching RAC denials of a hospital bill to the physician's claim that goes with that service and denying that payment as well. So far, RACs have done this very infrequently, because RACs work through fiscal intermediaries that pay the claims, and physicians have different fiscal intermediaries than hospitals. Now, however, CMS is consolidating these agencies so that physician and hospital payments are under one roof, she says.
Learn more about Pace Healthcare Consulting.
Related Articles on expansions of RAC activities.
RACs' Semi-Automated Review Explained
CMS Will Encourage RACs to Extrapolate Overpayments
National RAC Program Has Collected $313M Since Launch