How does a recovery auditor approach claims when reviewing payments?

The approach of a recovery auditor when reviewing claims is grounded in Medicare's established payment policies. These policies provide the framework for determining whether claims have been paid correctly and whether the services billed were medically necessary, appropriately documented, and aligned with the conditions specified by Medicare.

By utilizing Medicare's payment policies, recovery auditors can systematically assess claims for compliance, identify any overpayments, and ensure that the reimbursement aligns with the guidelines established by the Centers for Medicare & Medicaid Services (CMS). This use of established policies allows for a standardized method of review, promoting consistency and fairness in the auditing process.

Other strategies, such as creating new guidelines or collaborating with patient representatives, do not reflect the official role and responsibilities of recovery auditors. Additionally, focusing solely on new claims would limit the auditor's ability to identify patterns or anomalies in previously submitted claims, which is crucial for a comprehensive review process.