RAC Audit Response Process Template

Request to Record Map

One row per requested claim, carrying the payer's own stated reason and the specific document that answers it. Harrowdene's 40 sampled claims, 23 with findings.

The count that decides who does the work

Three answers, three different owners, three different odds. The first group is a filing clerk with the full encounter note. The second is twenty minutes of a clinician's time. The third is a conversation nobody wants to have. They arrive looking identical and stay that way until somebody counts them with money attached.

A row is not mapped because the chart is available. It is mapped when a named document with a date and an author answers the reason the payer actually gave.

Weighting the Sample

Ten minutes of arithmetic that inverts the worklist.

$3,584 divided by 40 sampled claims is $89.60 of mean overpayment, times 3,142 claims in the universe is $281,523. The demand reproduces from its own stated sample, which is the first thing to check and is not always true.

What a sampled claim is worth

A $47 finding on a $205 office visit outweighs a $1,240 claim that was not drawn. Every denial worklist in every practice is sorted by billed amount, and for a sampled demand that is close to exactly the wrong order. An hour spent on a chart outside the sample moves the number by nothing at all.

Which makes a concession expensive

Conceding one sampled claim to save the argument gives up $78.55 for every dollar it was worth. It also removes it from every later level, since an appellant disputing a sample or an extrapolation has to file for each sampled claim it wishes to appeal, in one request, within 60 calendar days of the last reconsideration for those claims. The tracker carries the count of live sampled claims as its own column, and the count only ever goes down.

Where a notice demands an extrapolated amount without stating the universe or the sample size, the multiplier cannot be computed and the demand cannot be checked. That absence is recorded as a finding rather than worked around.

Written before the letter arrives

Counsel Escalation Trigger

The decision to call a lawyer is made badly under time pressure. There is a number on the page, a due date two weeks out, and a strong sense that involving counsel will slow things down and cost money. That feeling is strongest in exactly the cases where the call matters most.

So the conditions get written down in advance, when nobody is deciding anything, and the check is mechanical. Whoever reads the notice works the list, marks each condition met or not met, and quotes the line that decided it.

Harrowdene met three on day one. Shaded rows above. The checked list is kept with the audit file whatever the answer was, because a record that the conditions were considered, and by whom, is worth having later.

Deadlines are real and the response still has to go. A met condition means the call happens the same day, not that the work pauses.