In what scenario would an Automated Review occur according to RAC audits?

An Automated Review occurs in situations where there is a strong indication of overpayment or underpayment, typically identified through established data analytics and algorithms. The key factor here is the "certainty of overpayment or underpayment." This means that the auditor's findings strongly suggest that there has been a billing mistake based on available data, rather than relying solely on subjective judgment or unclear guidelines. The focus on having "written guidelines" emphasizes that the determination of overpayment or underpayment is backed by concrete policies or regulations. This helps ensure that the automated processes align with existing healthcare laws and billing practices, promoting accuracy and compliance during the review.

In other scenarios, such as random selections of claims, the reviews wouldn’t be classified as Automated Reviews because they do not rely on specific evidence of inaccuracies. Similarly, when medical records are unavailable, it hampers the audit process and does not meet the criteria for an Automated Review, which relies on data that can be validated. Lastly, not all claims that receive denials would trigger an Automated Review; the denial could result from a variety of issues, and without clear evidence of financial discrepancies, these would not fall under the automated review process.