Automated vs. Complex RAC Audits
The RACs will primarily conduct two types of audits: automated and complex. An automated review relies on an analysis of claims data to make a determination. Automated reviews are generally based on clear policies outlined in the law, regulations or guidance. A complex review requires more in-depth analysis and almost always involves a request for medical records from the contractor. These may involve questions of medical necessity, proper documentation, and others where judgment is required. View the phase-in schedule for the different types of reviews.
If you are the target of a RAC audit, you may be able to get information about the type of review that was conducted based on the communication that you receive from the RAC. In cases where your first communication with the RAC is through a “demand letter,” you are often the subject of an automated review because the contractor did not need additional information from you to make the determination that an overpayment occurred. If you first receive a request for information from the RAC for records or other forms of documentation, you are likely the subject of complex review that will require determinations of medical necessity and proper documentation before the RAC can determine if an overpayment has been made. Individuals or practices that receive requests for records have 45 days to comply.
