RACs perform what type of review(s)?

Recovery Audit Contractors (RACs) are primarily involved in two types of reviews: automated and complex reviews. Automated reviews leverage software to identify billing errors and potential payment discrepancies based on pre-established criteria, which allows for a rapid evaluation of claims. In contrast, complex reviews involve a more detailed examination of medical records and claims, requiring professional judgment and expertise to determine if the services billed were medically necessary and appropriately documented.

Automated reviews tend to be quicker and focus on obvious errors that can be identified without in-depth analysis, while complex reviews delve deeper into the clinical and administrative details of a claim. Both types of reviews serve the goal of identifying incorrect payments and ensuring compliance with Medicare and Medicaid rules, ultimately helping to reduce improper payments and increase the accuracy of claims submissions. This dual approach allows RACs to efficiently track and address a wide range of compliance issues within the healthcare system.