09/16/2026

Recent RAC Monitor Article

This edition includes articles on

Precautions for Use of AI in Auditing: Why “Human in the Loop” Isn’t Just a Buzzword

Across the healthcare industry, the use of artificial intelligence (AI) has been growing exponentially. It’s changing the way medical records get reviewed, the way claims get scrutinized, and even the way clinical documentation gets written in the first place.

Payers, regulators, and provider organizations alike have begun leaning heavily on artificial intelligence, not as some futuristic concept, but as a working tool, already embedded in day-to-day operations. Many of our colleagues have discussed the surging impact this has had for regulatory oversight. On the data side, AI is being used to comb through massive volumes of claims and clinical data, flagging billing pattern outliers and quickly identifying deviations in a provider’s own practices, not just utilization that stands out from a peer group. This level of data analysis and auditing is at a scale human teams simply could not match working alone. What used to take analysts weeks of manual chart reviews and spreadsheet cross-referencing can now happen in a fraction of the time.

AI isn’t just analyzing data anymore, it’s stepping directly into the documentation process. In hospitals and behavioral health settings, AI‑powered tools are now acting as clinical scribes, listening to encounters and producing draft notes in real time. Others work behind the scenes as documentation improvement partners, scanning a finished note and flagging spots where more clinical detail or specificity could strengthen it. READ MORE

Payment Rates and Physician Shortages – Is There a Link?

I had vascular surgery recently. The anticipated overnight care resulted in a five-day inpatient stay, which was consistent with the typical length of stay associated with the assigned Diagnosis-Related Group (DRG).

But my surgery and stay were longer than initially expected due to the size of the specimen they removed from my blood vessel, my co-morbidities, and a reaction to the adhesives and CHG wipes, respectively. My time in the operating room (OR) was approximately five hours. The vascular surgeon was in the OR for approximately 4 hours. My surgeon billed $4,300, and Medicare allowed $735.

Somehow, $184 an hour for a vascular surgeon doesn’t seem appropriate, especially when one considers that the $735 also included the discharge and post-surgery follow-up visits in the global period. These diluted the $184 rate even more.

The Medicare Physician Fee Schedule (MPFS) is a resource-based payment system. Medicare does not generally pay any surgeon or physician based on the provider’s charge or the patient’s diagnosis alone. Instead, the Centers for Medicare & Medicaid Services (CMS) assigns each covered CPT®/HCPCS service a relative value, adjusts it for local costs, converts it to dollars, and then applies billing and payment rules. READ MORE

AI Fluency Is Now Essential – But Expertise Still Matters

The integration of ChatGPT, Claude, and similar generative artificial intelligence (AI) tools into everyday work has changed the baseline for professional productivity. Employees who use AI responsibly can research, analyze, draft, and communicate far faster than those who ignore it.

In many roles, competing without AI is becoming increasingly difficult. A professional supported by AI may summarize a regulation, compare contracts, prepare a presentation, draft computer code, and respond to correspondence in the time another employee needs to complete only one of those tasks.

Healthcare organizations should encourage responsible AI use. Revenue cycle, reimbursement, compliance, finance, coding, and health information management (HIM) professionals can use these tools to organize large amounts of information, identify inconsistencies, improve writing, automate repetitive processes, and develop better questions for investigation. Experienced professionals can also use AI to explore unfamiliar issues before consulting the appropriate specialist.READ MORE