CMS has made a major step on the way to leaving behind its current “pay and chase” approach to dealing with fraudulent claims, according to a new transmittal.

For claims submitted on or after Jan. 7, 2013 CMS will implement a new edit that checks the claims against the common working file (CWF) to identify high-risk bills the program shouldn’t pay. Reasons a claim might be picked up and denied under the new edit include services billed after a beneficiary’s death or incorrect beneficiary identification.

To avoid major payment disruptions to providers, CMS will reprogram the predictive modeling system as it goes, the transmittal states. For example, if the predictive model identifies 100 suspicious claims and 20 of those were found to be legitimate upon investigation, “the models will be refined to account for the characteristics of the 20 legitimate targets.”