Medicare Moves Forward with Phase III for Fraud Edit Module  

In April 2009, the Centers for Medicare & Medicaid Services (CMS) will implement a Fraud Edit Module that will allow claims payment and program safeguard contractors to create on-the-fly edits to immediate address fraud on a national level while leveraging the experience of individual states and regions. An analysis phase will start in January 2009 with final implementation of the system, April 6.

The impetus for the Fraud Edit Module stemmed from the development cost faced by carriers to create a system to deny claims with potentially improper payments associated with Infusion therapy. Implementing an edit system in Florida, Michigan, New Jersey, and New York resulted in over $10 million in savings but at substantial cost to the claims payment contractors.

As a fraud moves from state to state, a low-cost way to share and implement edits was key. The CMS convened a Fra...