When an RAC conducts a claim determination without human review of health records, this type of review is known as what?

When an RAC conducts a claim determination without human review of health records, this type of review is known as what?

• A. Automated review
• B. Complex review
• C. Detailed review
• D. Systematic review

Answer: (A)

An automated review is a process where the Recovery Audit Contractor (RAC) utilizes technology and algorithms to analyze claims for potential overpayments without the need for human intervention to review the patient health records. This method is efficient and often faster than manual reviews, as it allows for large volumes of claims to be processed quickly. Automated reviews are typically applied to straightforward cases where the data analysis can determine compliance with programming and billing regulations without needing nuanced clinical judgment that would require a human reviewer. In this context, automated reviews are beneficial for identifying clear instances of overbilling or non-compliance based on preset criteria, effectively allowing the RAC to manage resources and focus human oversight on more complex cases that require detailed clinical understanding.

An automated review is a process where the Recovery Audit Contractor (RAC) utilizes technology and algorithms to analyze claims for potential overpayments without the need for human intervention to review the patient health records. This method is efficient and often faster than manual reviews, as it allows for large volumes of claims to be processed quickly. Automated reviews are typically applied to straightforward cases where the data analysis can determine compliance with programming and billing regulations without needing nuanced clinical judgment that would require a human reviewer.

In this context, automated reviews are beneficial for identifying clear instances of overbilling or non-compliance based on preset criteria, effectively allowing the RAC to manage resources and focus human oversight on more complex cases that require detailed clinical understanding.