Future of Medicare Audits, Part III: Artificial Intelligence and the Audit-Free Future

Wednesday, 28 September 2016By Edward M. Roche, PhD, JD EDITOR’S NOTE: This is the third and final installment in an exclusive RACmonitor three-part series documenting the implementation of cyber audits by third-party auditors. In Part I of this series, we discussed the exploding number of Medicare claims and the inability of the current appeals system to handle the workload. We also reviewed how special computer algorithms are being used to downcode diagnosis-related group (DRG) claims and argued that these actions are not really “audits” because artificial intelligence (AI) algorithms using statistical comparison are being substituted for medical judgment.  In Part II, we examined the emerging arguments being made in “algorithm law,” but suggested that this area of litigation will need to be developed further, and that the type of experts…


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