Artificial Intelligence Audits Are Happening Now

Artificial Intelligence Audits Are Happening Now

Healthcare providers are starting to see the first claim audits based on analysis and determinations made by artificial intelligence (AI).

Although the technology is new, many of the issues remain the same. Especially when the companies that develop AI-based audit tools sell these tools and services to commercial insurance companies, AI-driven audits increasingly resemble audits of Medicare providers and suppliers performed by the Recovery Audit Contractors (RACs) or Unified Program Integrity Contractors (UPICs).

RACs and UPICs are Medicare contractors charged by the Centers for Medicare & Medicaid Services (CMS) to identify overpayments and underpayments made to providers and to facilitate return of overpayments to the Medicare Trust Fund. Primarily, RACs accomplish this by conducting audits and issuing repayment demands.

RACs are different from other types of Medicare contractors that conduct audits because RACs are paid on a contingency fee. That is, RACs receive a percentage of any funds they extract from providers, potentially making them significantly incentivized to deny claims and demand repayment even where there is no clinical or legal basis to do so. Sometimes it is difficult to assess whether an audit is being conducted by a RAC or a UPIC, which is important to know because different rules and regulations apply. For example, a RAC audit can only go back for review three years, whereas a UPIC can go back longer.

Sometimes, CMS disperses multiple contracts to one entity. CMS has come out and said, for example, that services such as blood transfusions will be audited. CMS guidelines mandate that blood transfusions administered in the hospital outpatient or physician office setting be billed with a maximum of one unit per patient, per date of service.

CMS guidelines also mandate that intravenous hydration therapy administered in the hospital outpatient or physician office setting be billed with a maximum of one unit per patient, per date of service (excluding claims with modifier 59).

Similarly, because few insurance carriers have developed sophisticated AI tools in-house, they often contract outside technology companies to provide such tools (and often, to conduct the audits themselves). These outside contractors are motivated to deny claims and identify alleged overpayments in order to retain the business of the insurance carrier. This motivation is further enhanced where the outside contractor is paid a percentage of the alleged overpayments that their AI tool identifies. Therefore, any provider should carefully scrutinize any such audit findings, much as they would scrutinize the findings of a similarly motivated RAC.

Furthermore, AI-driven audits also can raise concerns about the competence of the reviewer. RAC audits are often criticized for utilizing under-qualified coders, nurses, or others to attempt to review the documentation and complex decisions of physicians and specialists. Any AI tool is only as good as the underlying data on which it is built and trained. It is difficult to know how any AI tool has been trained, because technology companies generally consider this information proprietary. However, an AI tool that reviews physician records may make the same mistake or misunderstanding over and over again, because it simply does not understand the content, context, or the decision-making it is attempting to review. Providers should carefully review all audit findings, especially where any questions exist regarding the qualifications or competence of the reviewer.

Plus, adding more companies into the Medicare and Medicaid provider audit arena adds more incompetence. Already, RACs and UPICS and Medicare Administrative Contractors (MACs) conduct subpar provider audits.

It’s like the game “Telephone:” the more people are added, the more distorted the message becomes.

Print Friendly, PDF & Email
Facebook
Twitter
LinkedIn

Knicole C. Emanuel Esq.

For more than 20 years, Knicole has maintained a health care litigation practice, concentrating on Medicare and Medicaid litigation, health care regulatory compliance, administrative law and regulatory law. Knicole has tried over 2,000 administrative cases in over 30 states and has appeared before multiple states’ medical boards. She has successfully obtained federal injunctions in numerous states, which allowed health care providers to remain in business despite the state or federal laws allegations of health care fraud, abhorrent billings, and data mining. Across the country, Knicole frequently lectures on health care law, the impact of the Affordable Care Act and regulatory compliance for providers, including physicians, home health and hospice, dentists, chiropractors, hospitals and durable medical equipment providers. Knicole is partner at Nelson Mullins and a member of the RACmonitor editorial board and a popular panelist on Monitor Monday.

Related Stories

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

Navigating AI in Healthcare Revenue Cycle: Maximizing Efficiency, Minimizing Risks

Navigating AI in Healthcare Revenue Cycle: Maximizing Efficiency, Minimizing Risks

Michelle Wieczorek explores challenges, strategies, and best practices to AI implementation and ongoing monitoring in the middle revenue cycle through real-world use cases. She addresses critical issues such as the validation of AI algorithms, the importance of human validation in machine learning, and the delineation of responsibilities between buyers and vendors.

May 21, 2024
Leveraging the CERT: A New Coding and Billing Risk Assessment Plan

Leveraging the CERT: A New Coding and Billing Risk Assessment Plan

Frank Cohen shows you how to leverage the Comprehensive Error Rate Testing Program (CERT) to create your own internal coding and billing risk assessment plan, including granular identification of risk areas and prioritizing audit tasks and functions resulting in decreased claim submission errors, reduced risk of audit-related damages, and a smoother, more efficient reimbursement process from Medicare.

April 9, 2024
2024 Observation Services Billing: How to Get It Right

2024 Observation Services Billing: How to Get It Right

Dr. Ronald Hirsch presents an essential “A to Z” review of Observation, including proper use for Medicare, Medicare Advantage, and commercial payers. He addresses the correct use of Observation in medical patients and surgical patients, and how to deal with the billing of unnecessary Observation services, professional fee billing, and more.

March 21, 2024
Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets

Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets

Explore the top-10 federal audit targets for 2024 in our webcast, “Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets,” featuring Certified Compliance Officer Michael G. Calahan, PA, MBA. Gain insights and best practices to proactively address risks, enhance compliance, and ensure financial well-being for your healthcare facility or practice. Join us for a comprehensive guide to successfully navigating the federal audit landscape.

February 22, 2024
2025 IPPS Masterclass Day 3: MS-DRG Shifts and NTAPs

2025 IPPS Masterclass Day 3: MS-DRG Shifts and NTAPs

This third session in the ICD10monitor 2025 IPPS Masterclass will feature a review of FY25 changes to the MS-DRG methodology and new technology add-on payments (NTAPs), presented by senior healthcare consultant Laurie Johnson, with bonus insights and analysis from CDI expert Dr. Erica Remer.

August 15, 2024
2025 IPPS Masterclass Day 2: Master ICD-10-PCS Changes

2025 IPPS Masterclass Day 2: Master ICD-10-PCS Changes

This second session in the ICD10monitor 2025 IPPS Masterclass will feature a review of the FY25 changes to ICD-10-PCS codes, presented by senior healthcare consultant Laurie Johnson, with bonus insights and analysis from CDI expert Dr. Erica Remer.

August 14, 2024
2025 IPPS Masterclass Day 1: Master ICD-10-CM Changes

2025 IPPS Masterclass Day 1: Master ICD-10-CM Changes

This first session in the ICD10monitor 2025 IPPS Masterclass will feature a review of FY25 changes to ICD-10-CM codes and guidelines, SDoH, CCs/MCCs and revisions to the MCE, presented by senior healthcare consultant Laurie Johnson, with bonus insights and analysis from Dr. Erica Remer.

August 13, 2024
2025 IPPS Masterclass: Final Rule Update with Expert Insights and Analysis

2025 IPPS Masterclass: Final Rule Update with Expert Insights and Analysis

Only ICD10monitor delivers what you need: updates on must-know changes associated with the FY25 Inpatient Prospective Payment System (IPPS) Final Rule, including new ICD-10-CM/PCS codes, plus insights, analysis and answers to questions from the country’s most respected subject matter experts.

August 13, 2024

Trending News

Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →

Happy World Health Day! Our exclusive webcast, ‘2024 SDoH Update: Navigating Coding and Screening Assessment,’  is just $99 for a limited time! Use code WorldHealth24 at checkout.

SPRING INTO SAVINGS! Get 21% OFF during our exclusive two-day sale starting 3/21/2024. Use SPRING24 at checkout to claim this offer. Click here to learn more →