Random Selection of Claims

Can a RAC “stumble” across my files via random selection?

The RAC shall adhere to Section 935 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003, which prohibits the use of random claim selection for any purpose other than to establish an error rate…the RAC shall not use random review in order to identify cases for which it will order medical records from the provider…The RAC may not target a claim solely because it is a high dollar claim….

Whew, breathe a sigh of relief?

Nope, because instead of random selection, the RAC’s get to use something much more cost effective and powerful, they refer to it as “targeted review“.

Have you heard the term data mining used lately?

This is exactly what a targeted review is.  Somebody at the CMS or RAC can sit back and search for specific information inside the giant database the CMS keeps.

These powerful searches can turn up a list of procedure that have the highest number of “red flags”, meaning the highest potential for overpayment.  With this knowledge, the RAC is able to target with laser precision which files to go after.

With this capability, why waste time with random selection of files?