Requires the Secretary, with respect to Medicare audits, except when clear and convincing evidence exists of fraud or similar fault, to give a physician, provider of services, or provider of ambulance services (physicians or providers) the option of entering into: (1) an arrangement to offset alleged overpayments against future payments; or (2) a repayment plan with its carrier or fiscal intermediary to recoup such an overpayment.
Prohibits the Secretary from taking any action to recoup an overpayment or to impose a penalty during the period in which a physician or provider is appealing a determination that such an overpayment has been made or the amount of the overpayment.
Prohibits carriers, absent cause, from demanding the production of records or documentation before paying a Medicare claim.
Amends SSA title XI with respect to prohibited extensions of remuneration to a Medicare-eligible individual to influence a choice of provider, practitioner, or supplier. Excludes from the meaning of remuneration any waiver of copayment made in a written, mailed communication with existing patients.
Amends SSA title XVIII with regard to: (1) construction of hearing rights related to decisions to deny or not renew a physician enrollment agreement; (2) the post-payment audit process; (3) definitions relating to physicians or providers; and (4) the right to appeal on behalf of deceased beneficiaries.
Amends SSA title XVIII to require carriers, fiscal intermediaries, and contractors to conduct education programs (funded from the Medicare Integrity Program) for physicians and providers on billing, coding, cost reporting, and documentation regulations and procedures.
Outlines provisions with regard to certain information requests from physicians and providers.
Amends SSA title XVIII to provide for the inclusion of regulatory costs in the calculation of the sustainable growth rate with respect to the costs of physicians' services.
Prohibits the Health Care Financing Administration (HCFA) from implementing any new evaluation and management documentation guidelines under Medicare, unless it: (1) has provided for an assessment of the proposed guidelines by organizations representing physicians; (2) has established a plan that contains specific goals, including a schedule, for improving use of such guidelines; (3) has completed a minimum of four pilot projects to test such guidelines; and (4) finds that specified objectives will be met in the implementation of such guidelines.
[Congressional Bills 107th Congress]
[From the U.S. Government Publishing Office]
[S. 452 Introduced in Senate (IS)]
107th CONGRESS
1st Session
S. 452
To amend title XVIII of the Social Security Act to ensure that the
Secretary of Health and Human Services provides appropriate guidance to
physicians, providers of services, and ambulance providers that are
attempting to properly submit claims under the medicare program and to
ensure that the Secretary does not target inadvertent billing errors.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
March 5, 2001
Mr. Murkowski (for himself, Mr. Kerry, Mr. Kyl, Mr. Smith of New
Hampshire, Mr. Helms, Mr. Reid, Mrs. Lincoln, and Mr. Hagel) introduced
the following bill; which was read twice and referred to the Committee
on Finance
_______________________________________________________________________
A BILL
To amend title XVIII of the Social Security Act to ensure that the
Secretary of Health and Human Services provides appropriate guidance to
physicians, providers of services, and ambulance providers that are
attempting to properly submit claims under the medicare program and to
ensure that the Secretary does not target inadvertent billing errors.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Medicare Education
and Regulatory Fairness Act of 2001''.
(b) Table of Contents.--The table of contents of this Act is as
follows:
Sec. 1. Short title; table of contents.
Sec. 2. Findings.
Sec. 3. Definitions.
TITLE I--REGULATORY REFORM
Sec. 101. Prospective application of certain regulations.
Sec. 102. Requirements for judicial and regulatory challenges of
regulations.
Sec. 103. Prohibition of recovering past overpayments by certain means.
Sec. 104. Prohibition of recovering past overpayments if appeal
pending.
Sec. 105. Prohibition of random prepayment audits.
Sec. 106. Exception on prohibition of waiving medicare copayment.
Sec. 107. Effective date.
TITLE II--APPEALS PROCESS REFORMS
Sec. 201. Construction of hearing rights related to decisions to deny
or not renew a physician enrollment
agreement.
Sec. 202. Reform of post-payment audit process.
Sec. 203. Definitions relating to physicians, providers of services,
and providers of ambulance services.
Sec. 204. Right to appeal on behalf of deceased beneficiaries.
Sec. 205. Effective date.
TITLE III--EDUCATION COMPONENTS
Sec. 301. Designated funding levels for physician and provider
education.
Sec. 302. Information requests.
TITLE IV--SUSTAINABLE GROWTH RATE REFORMS
Sec. 401. Inclusion of regulatory costs in the calculation of the
sustainable growth rate.
TITLE V--POLICY DEVELOPMENT REGARDING E&M GUIDELINES
Sec. 501. Policy development regarding E&M Documentation Guidelines.
SEC. 2. FINDINGS.
Congress finds the following:
(1) Congress should focus more resources on and work with
physicians and health care providers to combat fraud in the
medicare program.
(2) The overwhelming majority of physicians and other
providers in the United States are law-abiding citizens who
provide important services and care to patients each day.
(3) Physicians and other providers of services that
participate in the medicare program often have trouble wading
through a confusing and sometimes even contradictory maze of
medicare regulations. Keeping track of the morass of medicare
regulations detracts from the time that physicians have to
treat patients.
(4) Due to the overly complex nature of medicare
regulations and the risk of being the subject of an aggressive
government investigation, many physicians are leaving the
medicare program, limiting the number of medicare patients they
see, or refusing to accept new medicare patients at all. If
this trend continues, health care for the millions of patients
nationwide who depend on medicare will be seriously
compromised. Congress has an obligation to prevent this from
happening.
(5) Regulatory fairness for physicians and providers as
well as increased access to education about medicare
regulations are necessary to preserve the integrity of our
health care system and provide for the health of our
population.
SEC. 3. DEFINITIONS.
In this Act:
(1) Billing.--The term ``billing'' includes any requirement
related to the content and timing of an order for care or a
plan of treatment by a physician, a provider of service, or a
provider of ambulance services.
(2) Carrier.--The term ``carrier'' means a carrier (as
defined in section 1842(f) of the Social Security Act (42
U.S.C. 1395u(f))) with a contract under title XVIII of such Act
to administer benefits under part B of such title.
(3) Extrapolation.--The term ``extrapolation'' has the
meaning given such term in section 1861(ww)(1) of the Social
Security Act (as added by section 203(a)).
(4) Fiscal intermediary.--The term ``fiscal intermediary''
means a fiscal intermediary (as defined in section 1816(a) of
the Social Security Act (42 U.S.C. 1395h(a))) with an agreement
under section 1816 of such Act to administer benefits under
part A or B of such title.
(5) HCFA.--The term ``HCFA'' means the Health Care
Financing Administration.
(6) Medicare program.--The term ``medicare program'' means
the health benefits program under title XVIII of the Social
Security Act (42 U.S.C. 1395 et seq.).
(7) Physician.--The term ``physician'' has the meaning
given such term in section 1861(r) of the Social Security Act
(42 U.S.C. 1395x(r)).
(8) Prepayment review.--The term ``prepayment review'' has
the meaning given such term in section 1861(ww)(2) of the
Social Security Act (as added by section 203(a)).
(9) Provider of services.--The term ``provider of
services'' has the meaning given such term in section 1861(u)
of the Social Security Act (42 U.S.C. 1395x(u)).
(10) Provider of ambulance services.--The term ``provider
of ambulance services'' means a provider of ambulance services
described in section 1861(s)(7) of the Social Security Act (42
U.S.C. 1395x(s)(7)).
(11) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.
TITLE I--REGULATORY REFORM
SEC. 101. PROSPECTIVE APPLICATION OF CERTAIN REGULATIONS.
Section 1871(a) of the Social Security Act (42 U.S.C. 1395hh(a)) is
amended by adding at the end the following new paragraphs:
``(3) Any regulation described under paragraph (2) shall
not take effect earlier than the effective date of the final
regulation. Any regulation described under such paragraph that
applies to an agency action, including any agency
determination, shall only apply as that regulation is in effect
at the time that agency action is taken.
``(4) The Secretary shall issue a final rule within 12
months of the date of publication of an interim final rule.
Such final rule shall provide responses to comments submitted
in response to the interim final rule. Such final rule shall
not establish or change a legal standard not raised in the
interim final rule unless a new 60-day comment period is
provided.
``(5) Carriers, fiscal intermediaries, and States pursuant
to an agreement under section 1864 shall not apply new policy
guidances or policy changes retroactively to services provided
before the date the new policy was issued.''.
SEC. 102. REQUIREMENTS FOR JUDICIAL AND REGULATORY CHALLENGES OF
REGULATIONS.
(a) Right To Challenge Constitutionality and Statutory Authority of
HCFA Regulations.--Section 1872 of the Social Security Act (42 U.S.C.
1395ii) is amended to read as follows:
``application of certain provisions of title ii
``Sec. 1872. Subject to subparagraphs (A), (B), (D), and (E) of
section 1848(i)(1), the provisions of sections 206 and 216(j), and of
subsections (a), (d), (e), (h), (i), (j), (k), and (l) of section 205,
shall also apply with respect to this title to the same extent as they
are applicable with respect to title II, except that--
``(1) in applying such provisions with respect to this
title, any reference therein to the Commissioner of Social
Security or the Social Security Administration shall be
considered a reference to the Secretary or the Department of
Health and Human Services, respectively; and
``(2) section 205(h) shall not apply with respect to any
action brought against the Secretary under section 1331, 1346,
1361, or 2201 of title 28, United States Code, regardless of
whether such action is unrelated to a specific determination of
the Secretary, that challenges--
``(A) the constitutionality of any provision of
this title;
``(B) the constitutionality of substantive or
interpretive rules of general applicability issued by
the Secretary to carry out this title'';
``(C) the Secretary's statutory authority to
promulgate such substantive or interpretive rules of
general applicability; or
``(D) a finding of good cause under subparagraph
(B) of the third sentence of section 553(b)(3) of title
5, United States Code, if used in the promulgation of
such substantive or interpretive rules of general
applicability.''.
(b) Administrative and Judicial Review of Secretary
Determinations.--Section 1866(h) of the Act (42 U.S.C. 1395cc(h)) is
amended--
(1) in paragraph (1), by striking ``(1)'' and all that
follows and inserting the following: ``(1) Except as provided
in paragraph (3), an institution or agency dissatisfied with a
determination by the Secretary that it is not a provider of
services or with a determination described in subsection (b)(2)
(regardless of whether such determination has been made by the
Secretary or by a State pursuant to an agreement entered into
with the Secretary under section 1864 and regardless of whether
the Secretary has imposed or may impose a remedy, penalty, or
other sanction on the institution or agency in connection with
such determination) shall be entitled to a hearing thereon by
the Secretary (after reasonable notice) to the same extent as
is provided in section 205(b), and to judicial review of the
Secretary's final decision after such hearing as is provided in
section 205(g), except that, in so applying such sections and
in applying section 205(l) thereto, any reference therein to
the Commissioner of Social Security or the Social Security
Administration shall be considered a reference to the Secretary
or the Department of Health and Human Services, respectively,
and such hearings are subject to the deadlines specified in
paragraph (2)f.'';
(2) by redesignating paragraph (2) as paragraph (3);
(3) by inserting after paragraph (1) the following new
paragraph:
``(2)(A)(i) Except as provided in clause (ii), an administrative
law judge shall conduct and conclude a hearing on a determination
described in subsection (b)(2) and render a decision on such hearing by
not later than the end of the 90-day period beginning on the date a
request for hearing has been timely filed.
``(ii) The 90-day period under clause (i) shall not apply in the
case of a motion or stipulation by the party requesting the hearing to
waive such period.
``(B) The Department Appeals Board of the Department of Health and
Human Services shall conduct and conclude a review of the decision on a
hearing described in subparagraph (A) and make a decision or remand the
case to the administrative law judge for reconsideration by not later
than the end of the 90-day period beginning on the date a request for
review has been timely filed.
``(C) In the case of a failure by an administrative law judge to
render a decision by the end of the period described in subparagraph
(A)(i), the party requesting the hearing may request a review by the
Departmental Appeals Board of the Departmental of Health and Human
Services, notwithstanding any requirements for a hearing for purposes
of the party's right to such a review.
``(D) In the case of a request described in subparagraph (D), the
Departmental Appeals Board shall review the case de novo. In the case
of the failure of the Departmental Appeals Board to render a decision
on such hearing by not later than the end of the 60-day period
beginning on the date a request for such a Department Appeals Board
hearing has been filed, the party requesting the hearing may seek
judicial review of the Secretary's decision, notwithstanding any
requirements for a hearing for purposes of the party's right to such
review.
``(E) In the case of a request described in subparagraph (D), the
court shall review the case de novo.''; and
(4) by adding at the end the following new paragraph:
``(4) An institution or agency dissatisfied with a finding or
determination by the Secretary, or by a State pursuant to an agreement
under section 1864, that the institution of agency if out of compliance
with any standard or condition of participation under this title
(except a determination described in subsection (b)(2)) shall be
entitled to a formal review or reconsideration of the finding or
determination, in accordance with the regulations prescribed by the
Secretary, prior to the imposition of any remedy, penalty, corrective
action, or other sanction in connection with the finding or
determination.''.
SEC. 103. PROHIBITION OF RECOVERING PAST OVERPAYMENTS BY CERTAIN MEANS.
(a) In General.--Subject to section 104 and except as provided in
subsection (b) and notwithstanding sections 1815(a), 1842(b), and
1861(v)(1)(A)(ii) of the Social Security Act (42 U.S.C. 1395g(a),
1395u(a), and 1395x(v)(1)(A)(ii)), or any other provision of law, for
purposes of applying sections 1842(b)(3)(B)(ii), 1866(a)(1)(B)(ii),
1870, and 1893 of such Act (42 U.S.C. 1395u(b)(3)(B)(ii),
1395cc(a)(1)(B)(ii), 1395gg, and 1395ddd) to pending and future audits,
the Secretary shall give a physician, provider of services, or provider
of ambulance services the option of entering into an arrangement to
offset alleged overpayments against future payments or entering into a
repayment plan with its carrier or fiscal intermediary to recoup such
an overpayment. Under such an arrangement or plan, a physician,
provider of services, or provider of ambulance services shall have up
to 3 years to offset or repay the overpayment if the amount of such
overpayment exceeds $5,000.
(b) Exception.--This section shall not apply to cases in which the
Secretary finds clear and convincing evidence of fraud or similar fault
on the part of the physician, provider of services, or provider of
ambulance services or in the case of overpayments for which an offset
arrangement is in place as of the date of the enactment of this Act.
SEC. 104. PROHIBITION OF RECOVERING PAST OVERPAYMENTS IF APPEAL
PENDING.
Notwithstanding any provision of law, for purposes of applying
sections 1842(b)(3)(B)(ii), 1866(a)(1)(B)(ii), 1870, and 1893 of the
Social Security Act (42 U.S.C. 1395u(b)(3)(B)(ii), 1395cc(a)(1)(B)(ii),
1395gg, and 1395ddd), the Secretary may not take any action (or
authorize any other person, including any fiscal intermediary, carrier,
and contractor under section 1893 of such Act (42 U.S.C. 1395ddd)) to
recoup an overpayment or to impose a penalty during the period in which
a physician, provider of services, or provider of ambulance services is
appealing a determination that such an overpayment has been made or the
amount of the overpayment.
SEC. 105. PROHIBITION OF RANDOM PREPAYMENT AUDITS.
Carriers may not, prior to paying a claim under the medicare
program, demand the production of records or documentation absent
cause.
SEC. 106. EXCEPTION ON PROHIBITION OF WAIVING MEDICARE COPAYMENT.
(a) In General.--Section 1128A(i)(6)(A) of the Social Security Act
(42 U.S.C. 1320a-7a(i)(6)(A)) is amended by inserting ``, except for
written, mailed communication with existing patients,'' before ``waiver
is not''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply to communications made on or after the date of the enactment of
this Act.
SEC. 107. EFFECTIVE DATE.
Except as otherwise provided in section 106(b), the amendments made
by this title shall take effect 60 days after the date of enactment of
this Act.
TITLE II--APPEALS PROCESS REFORMS
SEC. 201. CONSTRUCTION OF HEARING RIGHTS RELATED TO DECISIONS TO DENY
OR NOT RENEW A PHYSICIAN ENROLLMENT AGREEMENT.
Section 1842 of the Social Security Act (42 U.S.C. 1395u) is
amended by adding at the end the following new subsection:
``(u) A carrier decision to deny an initial physician enrollment
application and a carrier decision not to renew a physician enrollment
agreement shall be treated as an initial determination subject to the
same course of appeals as other initial determinations under section
1869.''.
SEC. 202. REFORM OF POST-PAYMENT AUDIT PROCESS.
(a) Carriers.--Section 1842 of the Social Security Act (42 U.S.C.
1395u), as amended by section 201, is further amended by adding at the
end the following new subsection:
``(v) In carrying out its contract under subsection (b)(3), with
respect to physicians' services or ambulance services, the carrier
shall provide for the recoupment of overpayments in the following
manner:
``(1)(A) During the 1-year period (or 18-month period in
the case of a physician who is in a practice with fewer than 10
full-time equivalent employees, including physicians) beginning
on the date on which a physician or provider of ambulance
services receives an overpayment, the physician or provider of
ambulance services may return the overpayment without penalty
or interest to the carrier making such overpayment if--
``(i) the carrier has not requested any relevant
record or file; or
``(ii) the case has not been referred before the
date of repayment to the Department of Justice or the
Office of Inspector General.
``(B) If a physician or provider of ambulance services
returns an overpayment under subparagraph (A), neither the
carrier, contractor under section 1893, nor any law enforcement
agency may begin an investigation or target such physician or
provider of ambulance services based on any claim associated
with the amount the physician or provider of ambulance services
has repaid.
``(2) If a carrier has decided to conduct a post-payment
audit of the physician or provider of ambulance services, the
carrier shall send written notice to the physician or provider
of ambulance services. If the physician or provider of ambulance
services practices in a rural area (as defined in section
1886(d)(2)(D)), such notice must be sent by registered mail.
``(3) The carrier or a contractor under section 1893 may
not recoup or offset payment amounts based on extrapolation (as
defined in section 1861(ww)(1)) for the first time that the
physician or provider of ambulance services is alleged as a
result of a post-payment audit to have received an overpayment.
``(4) As part of any written consent settlement
communication, the carrier or a contractor under section 1893
shall clearly state that the physician or provider of ambulance
services may submit additional information (including evidence
other than medical records) to dispute the overpayment amount
without waiving any administrative remedy or right to appeal the amount
of the overpayment.
``(5)(A) Each consent settlement communication from the
carrier or a contractor under section 1893 shall clearly state
that prepayment review (as defined in section 1861(ww)(2)) may
be imposed where the physician or provider of ambulance
services submits an actual or projected repayment to the
carrier or a contractor under section 1893. Subject to
subparagraph (D), any prepayment review shall cease when the
physician or provider of ambulance services has submitted
claims, found by carrier to be covered services and coded
properly for the same services that were the basis for
instituting the prepayment review, in a 180-day period or after
processing claims of at least 75 percent of the volume of the
claims (whichever occurs first) received by the carrier in the
full month preceding the start of the prepayment review. The
180-day period begins with the date of the carrier's written
notification that the physician or provider of ambulance
services is being placed on prepayment review.
``(B) Prepayment review may not be applied under this part
as a result of the voluntary submission of a claim or record
under section 1897(b)(2) or as a result of information provided
pursuant to a request under section 302(b) of the Medicare
Education and Regulatory Fairness Act of 2001.
``(C) Carrier prepayment and coverage policies and claims
processing screens used to identify claims for medical review
must be incorporated as part of the education programs on
medicare policy and proper coding made available to physicians
and providers of ambulance services.
``(D) The time and percentage claim limitations in
paragraph (5)(A) shall not apply to cases that have been
referred to the Department of Justice or the Office of the
Inspector General.''.
(b) Fiscal Intermediaries.--Section 1816 of the Social Security Act
(42 U.S.C. 1395h) is amended by adding at the end the following new
subsection:
``(m) In carrying out its agreement under this section, with
respect to payment for items and services furnished under this part,
the fiscal intermediary shall provide for the recoupment of
overpayments in the following manner:
``(1)(A) During the 1-year period beginning on the date on
which a provider of services receives an overpayment, the
provider of services may return the overpayment without penalty
or interest to the fiscal intermediary making such overpayment
if--
``(i) the fiscal intermediary has not requested any
relevant record or file; or
``(ii) the case has not been referred before the
date of repayment to the Department of Justice or the
Office of Inspector General.
``(B) If a provider of services returns an overpayment
under subparagraph (A), neither the fiscal intermediary,
contractor under section 1893, nor any law enforcement agency
may begin an investigation or target such provider of services
based on any claim associated with the amount the provider of
services has repaid.
``(2) If a fiscal intermediary has decided to conduct a
post-payment audit of the provider of services, the fiscal
intermediary shall send written notice to the provider of
services. If the provider of services practices in a rural area
(as defined in section 1886(d)(2)(D)), such notice must be sent
by registered mail.
``(3) The fiscal intermediary or a contractor under section
1893 may not recoup or offset payment amounts based on
extrapolation (as defined in section 1861(ww)(1)) for the first
time that the provider of services is alleged as a result of a
post-payment audit to have received an overpayment.
``(4) As part of any written consent settlement
communication, the fiscal intermediary or a contractor under
section 1893 shall clearly state that the provider of services
may submit additional information (including evidence other
than medical records) to dispute the overpayment amount without
waiving any administrative remedy or right to appeal the amount
of the overpayment.
``(5)(A) Each consent settlement communication from the
fiscal intermediary or a contractor under section 1893 shall
clearly state that prepayment review (as defined in section
1861(ww)(2)) may be imposed where the provider of services
submits an actual or projected repayment to the fiscal
intermediary or a contractor under section 1893. Subject to
subparagraph (D), any prepayment review shall cease when the
provider of services has submitted claims, found by the fiscal
intermediary to be covered services and coded properly for the
same services that were the basis for instituting the
prepayment review, in a 180-day period or after processing
claims of at least 75 percent of the volume of the claims
(whichever occurs first) received by the fiscal intermediary in
the full month preceding the start of the prepayment review.
The 180-day period begins with the date of the fiscal
intermediary's written notification that the provider of
services is being placed on prepayment review.
``(B) Prepayment review may not be applied under this part
as a result of the voluntary submission of a claim, cost
report, or record under section 1897(b)(2) or as a result of
information provided pursuant to a request under section 302(b)
of the Medicare Education and Regulatory Fairness Act of 2001.
``(C) Fiscal intermediary prepayment and coverage policies
and claims processing screens used to identify claims for
medical review must be incorporated as part of the education
programs on medicare policy and proper coding made available to
providers of services.
``(D) The time and percentage claim limitations in
paragraph (5)(A) shall not apply to cases that have been
referred to the Department of Justice or the Office of the
Inspector General.''.
SEC. 203. DEFINITIONS RELATING TO PHYSICIANS, PROVIDERS OF SERVICES,
AND PROVIDERS OF AMBULANCE SERVICES.
(a) In General.--Section 1861 of the Social Security Act (42 U.S.C.
1395 et seq.), as amended by section 102(b) and 105(b) of the Medicare,
Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (as
enacted into law by section 1(a)(6) of Public Law 106-554), is amended
by adding at the end the following new subsection:
``Definitions Relating to Physicians, Providers of Services, and
Providers of Ambulance Services
``(ww) For purposes of provisions of this title relating to
physicians, providers of services, and providers of ambulance services:
``(1) Extrapolation.--The term `extrapolation' means the
application of an overpayment dollar amount to a larger
grouping of claims than those in the audited sample to
calculate a projected overpayment figure.
``(2) Prepayment review.--The term `prepayment review'
means a carrier's and fiscal intermediary's practice of
withholding claim reimbursements from physicians, providers of
services, and providers of ambulance services pending review of
a claim even if the claims have been properly submitted and
reflect medical services provided.''.
SEC. 204. RIGHT TO APPEAL ON BEHALF OF DECEASED BENEFICIARIES.
Notwithstanding section 1870 of the Social Security Act (42 U.S.C.
1395gg) or any other provision of law, the Secretary shall permit any
physician, provider of services, and provider of ambulance services to
appeal any determination of the Secretary under the medicare program
on behalf of a deceased beneficiary where no substitute party is
available.
SEC. 205. EFFECTIVE DATE.
The amendments made by this title shall take effect at the end of
the 180-day period beginning on the date of the enactment of this Act.
TITLE III--EDUCATION COMPONENTS
SEC. 301. DESIGNATED FUNDING LEVELS FOR PHYSICIAN AND PROVIDER
EDUCATION.
(a) Education Programs for Physicians, Providers of Services, and
Providers of Ambulance Services.--Title XVIII of the Social Security
Act (42 U.S.C. 1395 et seq.) is amended by adding at the end the
following new section:
``education programs for physicians, providers of services, and
providers of ambulance services
``Sec. 1897. (a) Education Program Defined.--In this section, the
term `education programs' means programs undertaken in conjunction with
health care associations that focus on current billing, coding, cost
reporting, and documentation laws, regulations, program memoranda,
instructions to regional offices, and fiscal intermediary and carrier
manual instructions that place special emphasis on billing, coding,
cost reporting, and documentation errors that the Secretary has found
occur frequently and remedies for these improper billing, coding, cost
reporting, and documentation practices.
``(b) Conduct of Education Programs.--
``(1) In general.--Carriers, fiscal intermediaries, and
contractors under section 1893 shall conduct education programs
for any physician (or a designee), provider of services, or
provider of ambulance services that submits a claim or cost
report under paragraph (2)(A). Such carriers, intermediaries,
and contractors under section 1893 shall conduct outreach to
specifically contact physicians and their designees, providers
of services, and providers of ambulance services with fewer
than 10 full-time-equivalent employees (including physicians)
to implement education programs tailored to their education
needs and in proximity to their practices.
``(2) Provider education.--
``(A) Submission of claims, cost reports, and
records.--Any physician, provider of services, or
provider of ambulance services may voluntarily submit
any present or prior claim, cost report, or medical
record to the carrier or fiscal intermediary to
determine whether the billing, coding, and
documentation associated with the claim or cost report
is appropriate.
``(B) Prohibition of extrapolation.--No claim
submitted under subparagraph (A) is subject to any type
of extrapolation (as defined in section 1861(ww)(1)).
``(C) Safe harbor.--No submission of a claim, cost
report, or record under this section shall result in
the carrier, fiscal intermediary, a contractor under
section 1893, or any law enforcement agency beginning
an investigation or targeting an investigation based on
any claim, cost report, or record submitted under such
subparagraph.
``(3) Treatment of claims.--If the carrier or fiscal
intermediary finds a claim or cost report under paragraph (2)
to be improper, the physician, provider of services, or
provider of ambulance services shall have the following
options:
``(A) Correction of problems.--To correct the
documentation, coding, or billing problem to
appropriately substantiate the claim or cost report and
either--
``(i) remit the actual overpayment; or
``(ii) receive the appropriate additional
payment from the carrier or fiscal
intermediary.
``(B) Repayment.--To repay the actual overpayment
amount if the service is excluded from medicare
coverage under this title or if adequate documentation
does not exist.
``(4) Prohibition of physician and provider of services
tracking.--Carriers, fiscal intermediaries, and contractors
under section 1893 may not use the record of attendance or
information gathered during an education program conducted
under this section or the inquiry regarding claims or cost
reports under paragraph (2)(A) to select, identify, or track
such physician, provider of services, or provider of ambulance
services for the purpose of conducting any type of audit or
prepayment review.''.
(b) Funding of Education Programs.--
(1) Medicare integrity program.--Section 1893(b)(4) of such
Act (42 U.S.C. 1395ddd(b)(4)) is amended by adding at the end
the following new sentence: ``No less than 10 percent of the
program funds shall be devoted to the education programs for
physicians, providers of services, and providers of ambulance
services under section 1897.''.
(2) Carriers.--Section 1842(b)(3)(H) of such Act (42 U.S.C.
1395u(b)(3)(H)) is amended by adding at the end the following
new clause:
``(iii) No less than 2 percent of carrier
funds shall be devoted to the education
programs for physicians under section 1897.''.
(3) Fiscal intermediaries.--Section 1816(b)(1) of such Act
(42 U.S.C. 1395h(b)(1)) is amended--
(A) in subparagraph (A), by striking ``and'' at the
end;
(B) in subparagraph (B), by striking ``; and'' and
inserting a comma; and
(C) by adding at the end the following new
subparagraph:
``(C) that such agency or organization is using no
less than 1 percent of its funding for education
programs for providers of services and providers of
ambulance services under section 1897.''.
(c) Effective Date.--The amendments made by this section shall
apply to fiscal years beginning after the date of the enactment of this
Act.
SEC. 302. INFORMATION REQUESTS.
(a) Clear, Concise, and Accurate Answers.--Fiscal intermediaries
and carriers shall do their utmost to provide physicians, providers of
services, and providers of ambulance services with a clear, concise,
and accurate answer regarding billing and cost reporting questions
under the medicare program, and will give their true first and last
names to such physicians, providers of services, and providers of
ambulance services.
(b) Written Requests.--
(1) In general.--The Secretary shall establish a process
under which a physician, provider of services, or provider of
ambulance services may request, free of charge and in writing
from a fiscal intermediary or carrier, assistance in addressing
questions regarding coverage, billing, documentation, coding,
and cost reporting procedures under the medicare program and
then the fiscal intermediary or carrier shall respond in
writing within 30 business days with the correct substantive or
procedural answer.
(2) Use of written statement.--
(A) In general.--Subject to subparagraph (C), a
written statement under paragraph (1) may be used by
the physician, provider of services, or provider of
ambulance services who submitted the information
request and submitted claims in conformance with the
answer of the carrier or fiscal intermediary as proof
against a future audit or overpayment allegation under
the medicare program.
(B) Extrapolation prohibition.--Subject to
subparagraph (C), no claim submitted under this section
shall be subject to extrapolation, if the claim adheres
to the conditions set forth in the information
response.
(C) Limitation on application.--Subparagraphs (A)
and (B) shall not apply to cases of fraudulent billing.
(3) Safe harbor.--If a physician, provider of services, or
provider of ambulance services requests information under this
subsection, neither the fiscal intermediary, the carrier, a
contractor under section 1893 of the Social Security Act (42
U.S.C. 1395ddd), nor any law enforcement agency may begin an
investigation or target such physician or provider based on the
request.
(c) Broad Policy Guidance by the Secretary.--The Secretary shall
develop a mechanism to address written questions regarding medicare
policy and regulations, which are submitted by health care
associations. The Secretary shall issue such answers within 90 calendar
days from the date of the receipt of the question and shall make the
responses available to the public in an indexed, easily accessible
format.
(d) Notice of Changes in Policy.--Carriers and fiscal
intermediaries shall provide written, mailed notice within 30 calendar
days to physicians, providers of services, and providers of ambulance
services of all policy or operational changes to the medicare program.
Physicians, providers of services, and providers of ambulance services
shall have not less than 30 days to comply with such policy changes.
(e) Effective Date.--This section shall take effect 180 days after
the date of the enactment of this Act.
TITLE IV--SUSTAINABLE GROWTH RATE REFORMS
SEC. 401. INCLUSION OF REGULATORY COSTS IN THE CALCULATION OF THE
SUSTAINABLE GROWTH RATE.
(a) In General.--Section 1848(f)(2) of the Social Security Act (42
U.S.C. 1395w-4(f)(2)) is amended--
(1) by redesignating subparagraphs (A) through (D) as
clauses (i) through (iv), respectively;
(2) by striking ``Specification of growth rate.--The
sustainable growth rate'' and inserting ``Specification of
growth rate.--
``(A) In general.--The sustainable growth rate'';
and
(3) by adding at the end the following new subparagraphs:
``(B) Inclusion of sgr regulatory costs.--The
estimate established under clause (iv) or any successor
thereto shall include--
``(i) the impact on costs for physicians'
services resulting from regulations implemented
by the Secretary during the year for which the
sustainable growth rate is estimated, including
those regulations that may be implemented
during such year; and
``(ii) the costs described in subparagraph
(C).
``(C) Inclusion of other regulatory costs.--The
costs described in this subparagraph are per procedure
costs incurred by physicians' practices in complying
with regulations promulgated by the Secretary,
regardless of whether such regulation affects the fee
schedule established under subsection (b)(1).
``(D) Inclusion of costs in regulatory impact
analyses.--With respect to any regulation promulgated
that may impose a regulatory cost described in
subparagraph (B)(i) or (C) on a physician, the
Secretary shall include in the regulatory impact
analysis accompanying such regulation an estimate of
any such cost.
``(E) Inclusion of estimated cost on rural
physicians.--In promulgating regulations, the Secretary
shall specifically estimate the costs to rural
physicians and physicians practices in rural areas and
the estimated number of hours needed to comply with the
regulation.''.
(b) Effective Date.--The amendments made by subsection (a) shall
apply with respect to any estimate made (or regulation promulgated) by
the Secretary of Health and Human Services on or after 1 year after the
date of enactment of this Act.
TITLE V--POLICY DEVELOPMENT REGARDING E&M GUIDELINES
SEC. 501. POLICY DEVELOPMENT REGARDING E&M DOCUMENTATION GUIDELINES.
(a) In General.--HCFA may not implement any new evaluation and
management documentation guidelines (in this section referred to as
``E&M guidelines'') under the medicare program, unless HCFA--
(1) has provided for an assessment of the proposed
guidelines by organizations representing physicians;
(2) has established a plan that contains specific goals,
including a schedule, for improving use of such guidelines;
(3) has completed a minimum of 4 pilot projects consistent
with subsection (b) in at least 4 different HCFA regions
administered by 4 different carriers (to be specified by the
Secretary) to test such guidelines; and
(4) finds that the objectives described in subsection (c)
will be met in the implementation of such guidelines.
(b) Pilot Projects.--
(1) Length and consultation.--Each pilot project under this
subsection shall--
(A) be of sufficient length to allow for
preparatory physician and carrier education, analysis,
and use and assessment of potential E&M guidelines; and
(B) be conducted, throughout the planning and
operational stages of the project, in consultation with
organizations representing physicians.
(2) Peer review pilot projects.--Of the pilot projects
conducted under this subsection--
(A) at least one shall focus on a peer review
method by physicians (not employed by a carrier) which
evaluates medical record information for claims
submitted by physicians identified as statistical
outliers relative to definitions published in the CPT
book;
(B) at least one shall be conducted for services
furnished in a rural area (as defined in section
1886(d)(2)(D) of the Social Security Act, 42 U.S.C.
1395ww(d)(2)(D)); and
(C) at least one shall be conducted in a setting
where physicians bill under physicians services in
teaching settings (described in section 415.150 of
title 42, Code of Federal Regulations).
(3) Banning of targeting of pilot project participants.--
Data collected under this subsection shall not be used as the
basis for overpayment demands or post-payment audits.
(4) Study of impact.--Each pilot project shall examine the
effect of the E&M guidelines on--
(A) different types of physician practices,
including those with few than 10 full-time employees
(including physicians); and
(B) the costs of physician compliance, including
education, implementation, auditing, and monitoring.
(c) Objectives for E&M Guidelines.--The objectives for E&M
guidelines specified in this subsection are as follows (relative to the
E&M guidelines and review policies in effect as of the date of the
enactment of this Act):
(1) Enhancing clinically relevant documentation needed to
code accurately and assess coding levels accurately.
(2) Decreasing the level of non-clinically pertinent and
burdensome documentation time and content in the record.
(3) Increased accuracy by carrier reviewers.
(4) Education of both physicians and reviewers.
(5) Promote appropriate use of E&M codes by physicians and
their staffs.
(6) The extent to which the tested E&M documentation
guidelines substantially adhere to the CPT coding definitions
and rules.
(d) Report on How Met Pilot Project Objectives.--HCFA shall submit
a report to the Committees on Energy and Commerce and Ways and Means of
the House of Representatives, the Committee on Finance of the Senate,
and the Practicing Physicians Advisory Council, six months after the
conclusion of the pilot projects. Such report shall include the extent
to which the pilot projects met the objectives specified in subsections
(b)(4) and (c).
<all>
Introduced in Senate
Sponsor introductory remarks on measure. (CR S1818-1819)
Read twice and referred to the Committee on Finance. (text of measure as introduced: CR S1819-1823)
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