What type of review utilizes a "human review" of medical records in RAC audits?

The type of review that utilizes a "human review" of medical records in Recovery Audit Contractor (RAC) audits is a complex review. This in-depth process involves healthcare professionals, such as medical doctors or certified auditors, who evaluate the documentation and coding of claims to ensure compliance with regulatory requirements. Complex reviews are typically triggered when a claim meets specific criteria that warrant a more detailed examination beyond automated checks.

These reviews are essential because they address more nuanced clinical aspects that an automated review might miss. Automated reviews rely on software algorithms to check for billing errors based on predetermined rules, but they lack the ability to assess the context of medical necessity or the appropriateness of care within the same depth as a human reviewer. By engaging human expertise, complex reviews ensure a thorough evaluation that can lead to better compliance and can assist in identifying potential overpayments or underpayments.