Medicare Fraud Edit Module
The concept for the Fraud Edit Module began as a result of the Infusion Therapy fraud in South Florida. First Coast Service Options (a Medicare Carrier in Florida) developed a series of edits to flag claims with potential improper payments associated with Infusion Therapy for further review and denials. The edits have helped to reduce improper payments in Florida, but with a considerable cost to FCSO operating budget. Data suggested that Infusion Therapy fraud was moving to Michigan and NJ/NY. WPS and NGS developed similar edits to address this same issue. In Michigan, these edits have been able to save close to $6.8 M in improper payments and $3.1M in NJ and NY. Programming these edits, and associated reviews, requires a considerable operating expense for contractors. As the fraud moves from state to state, the need for a low-cost way to share and implement edits on the fly becomes clear. One option is to develop a shared system solution to meet this need.
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: March 07, 2008
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