Medicare and Medicaid Fighting Fraud and Abuse to Save Taxpayers' Dollars Act or Medicare and Medicaid FAST Act - Amends part D (Prescription Drug Benefits) of title XVIII (Medicare) of the Social Security Act (SSA) to direct the Secretary of Health and Human Services (HHS) to prohibit sponsors of prescription drug plans (PDPs) from paying claims for prescription drugs that do not include the valid National Provider Identifier for the drug's prescriber.
Directs the Secretary of HHS to establish procedures and rules to restrict access to the National Provider Identifier Registry in order to deter fraudulent use of it.
Amends SSA title XIX (Medicaid), for any state that has established a State Prescription Drug Monitoring Program meeting certain requirements, to decrease by 10% the federal medical assistance percentage (FMAP) with respect to any amounts recovered by or paid to the state related to an overpayment due to fraud, waste, or abuse. Allows the state to use such amounts to support its State Prescription Drug Monitoring Program.
Directs the Secretary of HHS and the Attorney General jointly to establish a Commission to examine interoperability and other issues related to State Prescription Drug Monitoring Programs.
Directs the Attorney General to: (1) update daily the Drug Enforcement Administration (DEA) database of persons registered to manufacture, distribute, or dispense a controlled substance under the Controlled Substances Act to reflect any changes in the information in the Death Master File of the Social Security Administration; (2) agree with the Commissioner of Social Security to obtain death information in order to update such database; (3) establish procedures and rules to restrict access to the database to deter its fraudulent use; and (4) establish procedures and rules to review and investigate pharmacy claims under Medicare part D that contain a registration number not assigned to a practitioner by the Attorney General under the Controlled Substances Act.
Amends SSA title XVIII to require certain annual reports to describe the types and financial costs to the Medicare program of improper payment vulnerabilities identified by Recovery Audit Contractors (RACs).
Requires the Secretary of HHS to develop a plan to revise the beneficiary incentive program under the Health Instance Portability and Accountability Act of 1996 (HIPAA) to encourage greater participation by individuals in reporting fraud and abuse in the Medicare program.
Requires the Secretary of HHS to: (1) establish and implement procedures to eliminate the unnecessary collection, use, and display of Social Security account numbers of Medicare beneficiaries; and (2) ensure that each newly issued Medicare identification card meets specified requirements.
Directs the Secretary of HHS to establish a pilot program utilizing smart card technology to evaluate its applicability to the Medicare program and whether such cards would be effective in preventing Medicare fraud.
Directs the Secretary of HHS to establish policies and procedures for a process to require prior authorization for initial claims for reimbursement for standard power wheelchairs.
Requires the Secretary of HHS, the HHS Inspector General, and the Attorney General to increase coordination and data sharing.
Directs the Secretary of HHS to establish: (1) automated prepayment review of all Medicare claims, (2) a plan to facilitate the inclusion of states in the Medicare-Medicaid Data Match Program, and (3) a plan that allows each state Medicaid agency access to relevant data on improper or erroneous Medicare payments for items or services for dual eligible individuals.
Prohibits Medicaid payments as well as payments under SSA title XXI (State Children's Health Insurance Program) (CHIP) unless a claim contains a valid beneficiary identification number and a valid National Provider Identifier.
Directs the Secretary to establish Medicare administrative contractor error reduction incentives.
Requires the provider enrollment process and provider screening to be separate from any contract to serve as a Medicare administrative contractor.
Directs the Secretary of HHS to report to Congress on measurable metrics for improving Medicare contractor performance.
Amends SSA title XI to establish penalties for the illegal distribution of a Medicare, Medicaid, or CHIP beneficiary identification number or billing privileges.
[Congressional Bills 112th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3399 Introduced in House (IH)]
112th CONGRESS
1st Session
H. R. 3399
To amend titles XVIII and XIX of the Social Security Act to curb waste,
fraud, and abuse in the Medicare and Medicaid programs.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
November 10, 2011
Mr. Roskam (for himself and Mr. Carney) introduced the following bill;
which was referred to the Committee on Energy and Commerce, and in
addition to the Committees on Ways and Means and the Judiciary, for a
period to be subsequently determined by the Speaker, in each case for
consideration of such provisions as fall within the jurisdiction of the
committee concerned
_______________________________________________________________________
A BILL
To amend titles XVIII and XIX of the Social Security Act to curb waste,
fraud, and abuse in the Medicare and Medicaid programs.
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 and
Medicaid Fighting Fraud and Abuse to Save Taxpayers' Dollars Act'' or
the ``Medicare and Medicaid FAST Act''.
(b) Table of Contents.--The table of contents of this Act is as
follows:
Sec. 1. Short title; table of contents.
TITLE I--PREVENTING PRESCRIPTION DRUG WASTE, FRAUD, AND ABUSE
Sec. 101. Requiring valid National Provider Identifiers of prescribers
on pharmacy claims and limiting access to
the National Provider Identifier Registry.
Sec. 102. Encouraging the establishment of State prescription drug
monitoring programs.
Sec. 103. Updating of DEA database of controlled substances providers.
TITLE II--CURBING IMPROPER PAYMENTS
Sec. 201. Addressing vulnerabilities identified by Recovery Audit
Contractors.
Sec. 202. Improving Senior Medicare Patrol and fraud reporting rewards.
Sec. 203. Prohibiting the display of Social Security account numbers on
newly issued Medicare identification cards
and communications provided to Medicare
beneficiaries.
Sec. 204. Requiring prior authorization of initial claims for standard
power wheelchairs.
Sec. 205. Strengthening Medicaid program integrity through flexibility.
TITLE III--IMPROVING DATA SHARING ACROSS AGENCIES AND PROGRAMS
Sec. 301. Improving data sharing across agencies and programs.
Sec. 302. Expanding automated prepayment review of Medicare claims.
Sec. 303. Improving the sharing of data between the Federal Government
and State Medicaid programs.
Sec. 304. Improving claims processing and detection of fraud within the
Medicaid and CHIP programs.
Sec. 305. Reports.
TITLE IV--IMPROVING CMS CONTRACTOR PERFORMANCE
Sec. 401. Establishing Medicare administrative contractor error
reduction incentives.
Sec. 402. Separating provider enrollment and screening from Medicare
administrative contractors.
Sec. 403. Developing measurable performance metrics for Medicare
contractors.
TITLE V--OTHER PROVISIONS
Sec. 501. Strengthening penalties for the illegal distribution of a
Medicare, Medicaid, or CHIP beneficiary
identification or billing privileges.
Sec. 502. Providing implementation funding.
TITLE I--PREVENTING PRESCRIPTION DRUG WASTE, FRAUD, AND ABUSE
SEC. 101. REQUIRING VALID NATIONAL PROVIDER IDENTIFIERS OF PRESCRIBERS
ON PHARMACY CLAIMS AND LIMITING ACCESS TO THE NATIONAL
PROVIDER IDENTIFIER REGISTRY.
(a) Requiring Valid National Provider Identifiers of Prescribers on
Pharmacy Claims.--Section 1860D-4(c) of the Social Security Act (42
U.S.C. 1395w-104(c)) is amended by adding at the end the following new
paragraph:
``(4) Requiring valid national provider identifiers of
prescribers on pharmacy claims.--
``(A) In general.--For plan year 2013 and
subsequent plan years, subject to subparagraph (B), the
Secretary shall prohibit PDP sponsors of prescription
drug plans from paying claims for prescription drugs
under this part that do not include the valid National
Provider Identifier for the drug's prescriber.
``(B) Procedures.--The Secretary shall establish--
``(i) procedures for determining the
validity of National Provider Identifiers under
subparagraph (A); and
``(ii) procedures for transferring to the
Inspector General of the Department of Health
and Human Services and appropriate law
enforcement agencies and other oversight
entities information on those National Provider
Identifiers and pharmacy claims, including
records related to such claims, that the
Secretary determines are invalid under clause
(i).
``(C) Report.--Not later than January 1, 2014, the
Inspector General of the Department of Health and Human
Services shall submit to Congress a report on the
effectiveness of the procedures established under
subparagraph (B).''.
(b) Limiting Access to National Provider Identifier Registry.--
(1) In general.--The Secretary of Health and Human Services
(in this subsection referred to as the ``Secretary''), in
consultation with the Attorney General, the Inspector General
of the Department of Health and Human Services, the Chairman of
the Federal Trade Commission, and affected parties (including
prescription drug plans under part D of title XVIII of the
Social Security Act (42 U.S.C. 1395w-101 et seq.), MA-PD plans
under part C of title XVIII of the Social Security Act (42
U.S.C. 1395w-21 et seq.), pharmacies, physicians, and pharmacy
computer vendors), shall establish procedures and rules to
restrict access to the National Provider Identifier Registry in
order to deter its fraudulent use.
(2) Access.--The procedures established under paragraph (1)
shall provide governmental and non-governmental entities, as
appropriate, access to such Registry under data use agreements
and in accordance with rules established by the Secretary under
such paragraph.
SEC. 102. ENCOURAGING THE ESTABLISHMENT OF STATE PRESCRIPTION DRUG
MONITORING PROGRAMS.
(a) In General.--Title XIX of the Social Security Act (42 U.S.C.
1396 et seq.) is amended by adding at the end the following new
section:
``SEC. 1947. ENCOURAGING THE ESTABLISHMENT OF STATE PRESCRIPTION DRUG
MONITORING PROGRAMS.
``(a) In General.--To encourage the establishment and use of a
State Prescription Drug Monitoring Program, notwithstanding sections
1905(b) and 1927(g), and for purposes of paragraphs (2)(B) and (3)(A)
of section 1903(d), if a State has established a State Prescription
Drug Monitoring Program that has been certified as meeting the
requirements under subsection (b), with respect to any amounts
recovered by or paid to a State subsequent to the date of such
certification that are related to an overpayment due to fraud, waste,
or abuse in connection the provision of covered services under the
State plan, the Federal medical assistance percentage with respect to
such amounts shall be decreased by 10 percentage points. A State may
use such amounts recovered by or paid to the State to support the State
Prescription Drug Monitoring Program established by the State.
``(b) Requirements.--For purposes of subsection (a), the
requirements of this subsection are that the Attorney General certifies
to the Secretary that the State has established a State Prescription
Drug Monitoring Program. In making a certification under the preceding
sentence, the Attorney General shall take into consideration
requirements with respect to Prescription Drug Monitoring Programs
under the Harold Rogers Prescription Drug Monitoring Program
administered by the Department of Justice or the National All Schedules
Prescription Electronic Reporting program administered by the
Department of Health and Human Services.
``(c) Commission To Examine Interoperability and Other Related
Issues.--
``(1) Establishment.--The Secretary and the Attorney
General shall jointly establish a Commission (in this
subsection referred to as the `Commission') to examine
interoperability and other issues related to State Prescription
Drug Monitoring Programs, including--
``(A) best practices with respect to uniform
electronic formats for the reporting, sharing, and
disclosure of information under such Programs; and
``(B) the ability to interface with such Programs.
``(2) Membership.--The Commission shall be composed of the
following members:
``(A) The Secretary.
``(B) The Attorney General.
``(C) The heads of other appropriate agencies (as
determined jointly by the Secretary and the Attorney
General).
``(D) Stakeholders appointed jointly by the
Secretary and the Attorney General.
``(3) No compensation of members.--
``(A) Non-federal employees.--A member of the
Commission who is not an officer or employee of the
Federal Government shall serve without compensation.
``(B) Federal employees.--A member of the
Commission who is an officer or employee of the Federal
Government shall serve without compensation in addition
to the compensation received for the services of the
member as an officer or employee of the Federal
Government.
``(4) Duration.--The Commission shall terminate on the date
that is 3 years after the date of the enactment of the Medicare
and Medicaid Fighting Fraud and Abuse to Save Taxpayers'
Dollars Act.''.
(b) Inclusion of Prescription Drug Monitoring Programs in Medicare
Part D Oversight.--Not later than 180 days after the date of the
enactment of this Act, the Secretary of Health and Human Services shall
submit to Congress a plan on how Medicare part D oversight contractors
and other oversight activities under part D of title XVIII of the
Social Security Act (42 U.S.C. 1395w-101 et seq.) can utilize State
Prescription Drug Monitoring Programs.
SEC. 103. UPDATING OF DEA DATABASE OF CONTROLLED SUBSTANCES PROVIDERS.
(a) In General.--
(1) Updating based on death master file.--Not less
frequently than on a daily basis, the Attorney General shall
update the database of the Drug Enforcement Agency of persons
registered to manufacture, distribute, or dispense a controlled
substance under part C of title II of the Controlled Substances
Act (21 U.S.C. 821 et seq.) to reflect any changes in the
information in the Death Master File of the Social Security
Administration.
(2) Updating based on other information reported to the
social security administration.--The Attorney General shall
enter into an agreement with the Commissioner of Social
Security to obtain information regarding deaths reported to the
Commissioner, including death information reported to the
Commissioner under section 205(r) of the Social Security Act
(42 U.5.C. 405(r)), in order to update the database of the Drug
Enforcement Agency of persons registered to manufacture,
distribute, or dispense a controlled substance under part C of
title II of the Controlled Substances Act (21 U.S.C. 821 et
seq.) to reflect any deaths reported to the Commissioner of
Social Security. The Attorney General shall take any actions
required by the agreement with the Commissioner to maintain the
confidentiality of such data and to assure that the data is
used solely for the purposes of this paragraph.
(b) Limiting Access to DEA Database of Registrants.--
(1) In general.--The Attorney General, in consultation with
the Secretary of Health and Human Services, the Inspector
General of the Department of Health and Human Services, the
Chairman of the Federal Trade Commission, and affected parties
(including prescription drug plans under part D of title XVIII
of the Social Security Act (42 U.S.C. 1395w-101 et seq.), MA-PD
plans under part C of title XVIII of the Social Security Act
(42 U.S.C. 1395w-21 et seq.), pharmacies, physicians, and
pharmacy computer vendors), shall establish procedures and
rules to restrict access to the database of the Drug
Enforcement Agency of persons registered to manufacturer,
distribute, or dispense a controlled substance under part C of
title II of the Controlled Substances Act (21 U.S.C. 821 et
seq.) in order to deter its fraudulent use.
(2) Access.--The procedures established under paragraph (1)
shall provide governmental and non-governmental entities, as
appropriate, access to such database under data use agreements
and in accordance with rules established by the Attorney
General under such paragraph.
(c) Review and Investigation of Invalid DEA Registration Numbers.--
The Attorney General, in consultation with the Secretary of Health and
Human Services, the Inspector General of the Department of Health and
Human Services, the Chairman of the Federal Trade Commission, and
affected parties (including prescription drug plans under part D of
title XVIII of the Social Security Act (42 U.S.C. 1395w-101 et seq.),
MA-PD plans under part C of title XVIII of the Social Security Act (42
U.S.C. 1395w-21 et seq.), pharmacies, physicians, and pharmacy computer
vendors), shall establish procedures and rules to review and
investigate pharmacy claims under such part D that contain a
registration number that was not assigned by the Attorney General under
the Controlled Substances Act (21 U.S.C. 801 et seq.) to a practitioner
(as defined in section 102 of such Act (21 U.S.C. 802)). Such
procedures shall include the matching of National Provider Identifiers
submitted under section 1860D-4(c)(4) of the Social Security Act, as
added by section 101(a), to such registration numbers and the
investigation of such registration numbers that are matched to a
National Provider Identifier determined to be invalid under such
section.
(d) Sense of Congress.--It is the sense of Congress that the
Attorney General should include in the updates required under
subsection (a) any other information determined relevant by the
Attorney General, such as information from State Medical Boards.
TITLE II--CURBING IMPROPER PAYMENTS
SEC. 201. ADDRESSING VULNERABILITIES IDENTIFIED BY RECOVERY AUDIT
CONTRACTORS.
Section 1893(h) of the Social Security Act (42 U.S.C. 1395ddd(h))
is amended--
(1) in paragraph (1)(C), by inserting ``and for provider
education and overpayment appeals'' before the period;
(2) in paragraph (8)--
(A) by striking ``report.--The Secretary'' and
inserting ``report.--
``(A) In general.--Subject to subparagraph (C), the
Secretary''; and
(B) by adding after subparagraph (A), as inserted
by subparagraph (A), the following new subparagraphs:
``(B) Inclusion of improper payment vulnerabilities
identified.--Each report submitted under subparagraph
(A) shall, subject to subparagraph (C), include--
``(i) a description of--
``(I) the types and financial cost
to the program under this title of
improper payment vulnerabilities
identified by recovery audit
contractors under this subsection; and
``(II) how the Secretary is
addressing such improper payment
vulnerabilities; and
``(ii) an assessment of the effectiveness
of changes made to payment policies and
procedures under this title in order to address
the vulnerabilities so identified.
``(C) Limitation.--The Secretary shall ensure that
each report submitted under subparagraph (A) does not
include information that the Secretary determines would
be sensitive or would otherwise negatively impact
program integrity.''; and
(3) by adding at the end the following new paragraph:
``(10) Addressing improper payment vulnerabilities.--The
Secretary shall address improper payment vulnerabilities
identified by recovery audit contractors under this subsection
in a timely manner.''.
SEC. 202. IMPROVING SENIOR MEDICARE PATROL AND FRAUD REPORTING REWARDS.
(a) In General.--The Secretary shall develop a plan, including
suggested legislative changes to implement such plan, under which the
Secretary shall revise the beneficiary incentive program under section
203(b) of the Health Insurance Portability and Accountability Act of
1996 (42 U.S.C. 1395b-5(b)) to encourage greater participation by
individuals to report fraud and abuse in the Medicare program. Such
plan shall include recommendations for ways to enhance rewards for
individuals reporting under the incentive program, including providing
a monetary reward prior to the full recovery of an overpayment.
(b) Public Awareness and Education Campaign.--The plan developed
under subsection (a) shall also require the Secretary to use the Senior
Medicare Patrols authorized under section 411 of the Older Americans
Act of 1965 (42 U.S.C. 3032) to conduct a public awareness and
education campaign to encourage participation in the revised
beneficiary incentive program under subsection (a).
(c) Submission of Plan.--Not later than 180 days after the date of
enactment of this Act, the Secretary shall submit to Congress the plan
developed under subsection (a).
(d) Definitions.--In this section:
(1) Medicare beneficiary.--The term ``Medicare
beneficiary'' means an individual entitled to, or enrolled for,
benefits under part A of title XVIII of the Social Security Act
(42 U.S.C. 1395c et seq.) or enrolled for benefits under part B
of such title (42 U.S.C. 1395j et seq.).
(2) Medicare program.--The term ``Medicare program'' means
the program under title XVIII of the Social Security Act (42
U.S.C. 1395 et seq.).
(3) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.
SEC. 203. PROHIBITING THE DISPLAY OF SOCIAL SECURITY ACCOUNT NUMBERS ON
NEWLY ISSUED MEDICARE IDENTIFICATION CARDS AND
COMMUNICATIONS PROVIDED TO MEDICARE BENEFICIARIES.
(a) In General.--Not later than 2 years after the date of enactment
of this Act, the Secretary of Health and Human Services, in
consultation with the Commissioner of Social Security, shall establish
and begin to implement procedures to eliminate the unnecessary
collection, use, and display of Social Security account numbers of
Medicare beneficiaries.
(b) Newly Issued Medicare Cards and Communications Provided to
Beneficiaries.--
(1) Newly issued cards.--
(A) In general.--Not later than 4 years after the
date of enactment of this Act, the Secretary of Health
and Human Services, in consultation with the
Commissioner of Social Security, shall ensure that each
newly issued Medicare identification card meets the
requirements described in subparagraph (B).
(B) Requirements.--
(i) In general.--Subject to clauses (ii)
and (iii), the requirements described in this
subparagraph are, with respect to a Medicare
identification card, that the card does not
display or electronically store (in an
unencrypted format) a Medicare beneficiary's
Social Security account number.
(ii) Exception.--The Secretary may waive
the requirements under clause (i) in the case
where the health insurance claim number of a
beneficiary is the Social Security number of
the beneficiary's spouse or of another
individual.
(iii) Use of partial account number.--The
Secretary of Health and Human Services, in
consultation with the Commissioner of Social
Security, may provide for the use of a partial
Social Security account number on a Medicare
identification card if the Secretary determines
that such use does not allow an unacceptable
risk of fraudulent use.
(2) Communications provided to beneficiaries.--Not later
than 4 years after the date of enactment of this Act, the
Secretary of Health and Human Services shall prohibit the
display of a Medicare beneficiary's Social Security account
number on written or electronic communication provided to the
beneficiary unless the Secretary, in consultation with the
Commissioner of Social Security, determines that inclusion of
Social Security account numbers on such communications is
essential for the operation of the Medicare program.
(c) Medicare Beneficiary Defined.--In this section, the term
``Medicare beneficiary'' means an individual who is entitled to, or
enrolled for, benefits under part A of title XVIII of the Social
Security Act or enrolled under part B of such title.
(d) Conforming Amendments.--
(1) Reference in the social security act.--Section
205(c)(2)(C) of the Social Security Act (42 U.S.C.
405(c)(2)(C)) is amended--
(A) by moving clause (x), as added by section
1414(a)(2) of the Patient Protection and Affordable
Care Act (Public Law 111-148), 6 ems to the left;
(B) by redesignating clause (x), as added by
section 2(a)(1) of the Social Security Number
Protection Act of 2010 (42 U.S.C. 1305 note), as clause
(xii); and
(C) by adding after clause (xii), as redesignated
by subparagraph (B), the following new clause:
``(xiii) Subject to section 203 of the Medicare and Medicaid
Fighting Fraud and Abuse to Save Taxpayers' Dollars Act, social
security account numbers shall not be displayed on Medicare
identification cards or on communications provided to Medicare
beneficiaries.''.
(2) Access to information.--Section 205(r) of the Social
Security Act (405 U.S.C. 405(r)) is amended by adding at the
end the following new paragraph:
``(10) To prevent and identify fraudulent activity, the
Commissioner shall upon the request of the Attorney General or upon the
request of the Secretary of Health and Human Services enter into a
reimbursable agreement with the Attorney General or the Secretary to
provide information collected under paragraph (1) if--
``(A) the requirements of subparagraphs (A) and (B) of
paragraph (3) are met; and
``(B) such agreement includes appropriate provisions to
protect the confidentiality of information provided by the
Commissioner under such agreement.''.
(e) Pilot Program.--
(1) Establishment.--The Secretary shall establish a pilot
program utilizing smart card technology to evaluate--
(A) the applicability of smart card technology to
the Medicare program under title XVIII of the Social
Security Act (42 U.S.C. 1395 et seq.), including the
applicability of such technology to Medicare
beneficiaries or Medicare providers; and
(B) whether such cards would be effective in
preventing fraud under the Medicare program.
(2) Implementation.--
(A) Initial implementation.--The Secretary shall
implement the pilot program under this subsection not
later than 1 year after the date of enactment of this
Act.
(B) Scope and duration.--The Secretary shall
conduct the pilot program--
(i) in not less than 2 States; and
(ii) for a period of not less than 180 days
or more than 2 years.
(3) Report.--Not later than 12 months after the completion
of the pilot program under this subsection, the Secretary shall
submit to the appropriate committees of Congress and make
available to the public a report that includes the following:
(A) A summary of the pilot program and findings,
including--
(i) the costs or savings to the Medicare
program as a result of the implementation of
the pilot program;
(ii) whether the use of smart card
technology resulted in improvements in the
quality of care provided to Medicare
beneficiaries under the pilot program; and
(iii) whether such technology was useful in
preventing or detecting fraud, waste, and abuse
in the Medicare program.
(B) Recommendations regarding whether the use of
smart card technology should be expanded under the
Medicare program.
(4) Definitions.--In this subsection:
(A) Medicare beneficiary.--The term ``Medicare
beneficiary'' means an individual entitled to, or
enrolled for, benefits under part A of title XVIII of
the Social Security Act (42 U.S.C. 1395c et seq.) or
enrolled for benefits under part B of such title (42
U.S.C. 1395j et seq.).
(B) Medicare provider.--The term ``Medicare
provider'' includes a provider of services (as defined
in section 1861(u) of the Social Security Act (42
U.S.C. 1395x(u))) and a supplier (as defined in section
1861(d) of such Act (42 U.S.C. 1395x(d))).
(C) Secretary.--The term ``Secretary'' means the
Secretary of Health and Human Services.
(D) Smart card.--The term ``smart card'' means
identification used by a Medicare beneficiary or a
Medicare provider that includes anti-fraud attributes.
Such a card--
(i) may rely on existing commercial data
transfer networks or on a network of
proprietary card readers or databases; and
(ii) may include--
(I) cards using technology adapted
from the financial services industry;
(II) cards containing individual
biometric identification, provided that
such identification is encrypted and
not contained in any central database;
(III) cards adapting technology and
processes utilized in the TRICARE
program under chapter 55 of title 10,
United States Code, or by the Veterans
Administration; or
(IV) such other technology as the
Secretary determines appropriate.
SEC. 204. REQUIRING PRIOR AUTHORIZATION OF INITIAL CLAIMS FOR STANDARD
POWER WHEELCHAIRS.
Section 1834(a) of the Social Security Act (42 U.S.C. 1395m(a)) is
amended by adding at the end the following new paragraph:
``(22) Prior authorization for standard power
wheelchairs.--
``(A) In general.--Not later than 270 days after
the date of the enactment of this paragraph, the
Secretary shall establish policies and procedures for a
process to require prior authorization for initial
claims for reimbursement under this title for standard
power wheelchairs. Such process shall include and be
consistent with the following:
``(i) The process shall include
development, formatting, and approval of
documents, including a comprehensive medical
necessity evaluation form for physicians.
``(ii) The process shall provide 7 days for
the Secretary, acting through the Centers for
Medicare & Medicaid Services, to review and
determine whether the information provided
meets coverage requirements.
``(iii) The Secretary shall include
stakeholders in the development of the process,
including representatives from the Centers for
Medicare & Medicaid Services, clinicians,
consumer groups, and national trade
associations representing suppliers of durable
medical equipment.
``(iv) Not later than 9 months after the
date of the enactment of this paragraph, the
Secretary shall have developed and approved an
online process for prior authorization of
standard power wheelchairs.
``(v) For standard power wheelchairs
furnished not later than 12 months after the
date of approval of such online process, the
Secretary shall implement the requirement for
prior authorization under this paragraph.
``(vi) No later than 12 months after
enactment of this paragraph, the Secretary,
working with stakeholders, shall make
recommendations to Congress for an electronic
review process for other durable medical
equipment items deemed at high risk.
``(B) Prior authorization defined.--In this
paragraph, the term `prior authorization' means an
electronic process to evaluate medical documentation in
order to determine whether medical necessity and
coverage requirements have been met for a claim for a
standard power wheelchair.''.
SEC. 205. STRENGTHENING MEDICAID PROGRAM INTEGRITY THROUGH FLEXIBILITY.
Section 1936 of the Social Security Act (42 U.S.C. 1396u-6) is
amended--
(1) in subsection (a), by inserting ``, or otherwise,''
after ``entities''; and
(2) in subsection (e)--
(A) in paragraph (1), in the matter preceding
subparagraph (A), by inserting ``(including the costs
of equipment, salaries and benefits, and travel and
training)'' after ``Program under this section''; and
(B) in paragraph (3), by striking ``by 100'' and
inserting ``by 100, or such number as determined
necessary by the Secretary to carry out the Program,''.
TITLE III--IMPROVING DATA SHARING ACROSS AGENCIES AND PROGRAMS
SEC. 301. IMPROVING DATA SHARING ACROSS AGENCIES AND PROGRAMS.
(a) In General.--In order to ensure that the Secretary, Medicare
program safeguard contractors and other oversight contractors (as
defined in subsection (g)(4)), the Inspector General of the Department
of Health and Human Services, the Attorney General, and State and local
law enforcement are able to operate with greater coordination to curb
fraud and improper payments, the Secretary, the Inspector General of
the Department of Health and Human Services, and the Attorney General
shall provide for increased coordination and data sharing as described
in the succeeding subsections.
(b) Improving Data Sharing Internally and With CMS Contractors.--
(1) In general.--The Secretary shall establish policies and
procedures to ensure that claims and other data, including the
data described in paragraph (3), is accessible to Medicare
program safeguard contractors and other oversight contractors
not less frequently than on a daily basis.
(2) Analysis of data.--The Secretary shall require Medicare
program safeguard contractors and other oversight contractors
to analyze the data accessed under paragraph (1) on an ongoing
basis for purposes of conducting pre- and post-payment reviews
under the Medicare program.
(3) Data described.--The following data is described in
this paragraph:
(A) Claims payment, claims denial, and other claims
data under the Medicare program from the common working
file and the Medicare national claims history database.
(B) Data on providers of services and suppliers
under the Medicare program, including data from the
Medicare Provider Enrollment, Chain, and Ownership
System (PECOS) of the Centers for Medicare & Medicaid
Services.
(C) Medicare beneficiary data, including data from
the Enrollment DataBase of the Centers for Medicare &
Medicaid Services.
(c) Provider Database Reviews and Verification.--
(1) In general.--
(A) Review and update of medicare provider
databases.--The Secretary shall establish policies and
procedures, which may include contractors, to review
and update on a daily basis Medicare provider
databases, including the review and update of the
Medicare Provider Enrollment, Chain, and Ownership
System (PECOS) of the Centers for Medicare & Medicaid
Services against death data of the Social Security
Administration, for accuracy and completeness. Such
policies and procedures shall also include data matches
on a daily basis, as determined appropriate by the
Secretary, against other databases as determined
appropriate by the Secretary, including the database of
the Drug Enforcement Agency of persons registered to
manufacture, distribute, or dispense a controlled
substance under part C of title II of the Controlled
Substances Act (21 U.S.C. 821 et seq.), State medical
licensing data, databases of suspended or debarred
Federal contractors, including the Excluded Parties
List System of the General Services Administration, the
Debt Check program of the Department of the Treasury, a
list of incarcerated individuals from the Department of
Justice and each State's Department of Corrections, and
the List of Excluded Individuals/Entities of the Office
of Inspector General of the Department of Health and
Human Services.
(B) Consultation.--The policies and procedures
under subparagraph (A) shall require the Secretary to
periodically consult with external organizations,
including the Federation of State Medical Boards, to
determine data sources and screening tools best suited
to detect fraudulent applications for enrollment under
section 1866(j) of the Social Security Act (42 U.S.C.
1395cc(j)) submitted by providers of medical or other
items or services and suppliers under the Medicare
program.
(C) Data matching.--
(i) In general.--The policies and
procedures under subparagraph (A) may include
entering into agreements with the Commissioner
of Social Security pursuant to section 205(r)
of the Social Security Act (42 U.S.C. 405(r))
to match data against the death information
maintained by the Commissioner, and matching
against the database of the Drug Enforcement
Agency of persons registered to manufacture,
distribute, or dispense a controlled substance
under part C of title II of the Controlled
Substances Act (21 U.S.C. 821 et seq.), and
other Federal databases, as determined
appropriate by the Secretary.
(ii) Confidentiality of data obtained.--The
Secretary shall take any actions required by an
agreement described in clause (i) or any other
agreement with the Commissioner of Social
Security to obtain data from the Commissioner
for purposes of this section to maintain the
confidentiality of data obtained from the
Commissioner and to assure that the data is
used solely for the purposes of this section.
(D) Ongoing analysis.--The Secretary shall use
analytic software for the conduct of ongoing analysis
of Medicare provider databases described in
subparagraph (A) to verify and update data. The
Secretary may use commercial database sources for
purposes of verifying such data.
(2) Access to national directory of new hires.--Section
453(j) of the Social Security Act (42 U.S.C. 653(j)) is amended
by adding at the end the following new paragraph:
``(12) Provision of new hire information to the centers for
medicare & medicaid services, the inspector general of the
department of health and human services, and applicable state
health subsidy programs.--The National Directory of New Hires
shall provide the Administrator of the Centers for Medicare &
Medicaid Services and the Inspector General of the Department
of Health and Human Services and, for purposes of carrying out
section 1413(c)(3)(A)(ii) of Public Law 111-148, each
applicable State health subsidy program (as defined in section
1413(e) of such Public Law) with all information in the
National Directory. With respect to the Inspector General, such
authority is in addition to any authority conferred under the
Inspector General Act (5 U.S.C. App. 3).''
(3) Access to list of convicted individuals.--The Attorney
General shall provide the Secretary of Health and Human
Services access to a list of convicted individuals for use in
preventing waste, fraud, and abuse under the Medicare and
Medicaid programs.
(d) Beneficiary Database Review and Verification.--
(1) In general.--The Secretary shall establish policies and
procedures, which may include contractors, to review and update
on a daily basis Medicare beneficiary databases, including the
Enrollment DataBase of the Centers for Medicare & Medicaid
Services, for accuracy and completeness. Such policies and
procedures shall include data matches against death data of the
Social Security Administration and also on a daily basis, as
determined appropriate by the Secretary, other Federal
databases as determined appropriate by the Secretary, including
a list of incarcerated individuals from the Department of
Justice and each State's Department of Corrections.
(2) Ongoing analysis.--The Secretary shall use analytic
software for the conduct of ongoing analysis of Medicare
beneficiary databases described in paragraph (1) to verify and
update data supplied by providers of services and suppliers
under the Medicare program. The Secretary may use commercial
database sources for purposes of verifying such data.
(e) Continued Efforts on Integrated Data Repository and One PI
Project; Expanded Access by Agencies.--
(1) Continued efforts on integrated data repository and one
pi project.--
(A) In general.--The Secretary shall--
(i) continue to incorporate Medicare claims
and payment, provider, and beneficiary data
into the Integrated Data Repository under
section 1128J(a)(1) of the Social Security Act,
as added by section 6402(a) of the Patient
Protection and Affordable Care Act; and
(ii) fully implement the waste, fraud, and
abuse detection solution of the Centers for
Medicare & Medicaid Services, called the ``One
PI project''.
(B) Updating of idr on daily basis.--The Secretary
shall establish policies and procedures to ensure that
the Integrated Data Repository is updated with Medicare
claims payment data and data from the Medicare provider
databases described in subsection (c)(1) and Medicare
beneficiary databases described in subsection (d)(1),
including the common working file, on a daily basis.
(C) Access to idr.--The Secretary shall ensure that
Medicare program safeguard contractors and other
oversight contractors have access to the full range of
data contained in the Integrated Data Repository and
related analytic tools by not later than September 30,
2012. Such access shall include both real-time portal
access and other means in accordance with protocols
established by the Secretary.
(D) Law enforcement access.--The Secretary shall
ensure that Federal and other appropriate law
enforcement agencies, including the Inspector General
of the Department of Health and Human Services and the
Attorney General, have access to the full range of data
contained in the Integrated Data Repository and related
analytic tools by not later than September 30, 2012.
Such access shall include both real-time portal access
and other means in accordance with protocols
established by the Secretary.
(E) Date certain for inclusion of prepayment claims
data.--The Secretary shall ensure that the Integrated
Data Repository includes access to prepayment claims
data by not later than September 30, 2012.
(F) Date certain for inclusion of medicaid program
data.--The Secretary shall ensure that the Integrated
Data Repository includes access to or incorporates
Medicaid program data by not later than September 30,
2014 (or, if States are unable to provide certain data
to the Secretary by such date, a substantial amount of
the Medicaid program data that is available as of such
date).
(2) Expanded database access to appropriate state
entities.--
(A) Access to integrated data repository.--For
purposes of enhancing data sharing in order to identify
programmatic weaknesses and improving the timeliness of
analysis and actions to prevent waste, fraud, and
abuse, relevant State agencies, including the State
Medicaid plans under title XIX of the Social Security
Act, State child health plans under title XXI of such
Act, and State Medicaid fraud control units (as
described in section 1903(q) of the Social Security Act
(42 U.S.C. 1396b(q))), shall have access to the full
range of data contained in the Integrated Data
Repository, including the One PI system established
under the One PI project, as directed by the Secretary,
by not later than September 30, 2013. The Secretary
may, in consultation with the Inspector General of the
Department of Health and Human Services, give such
access to State attorneys general and State law
enforcement agencies.
(B) Conforming amendments.--Section 1128J(a)(2) of
the Social Security Act, as added by section 6402(a) of
the Patient Protection and Affordable Care Act (Public
Law 111-148) is amended--
(i) by striking ``DATABASES.--'' and
inserting ``DATABASES.--''
``(A) Access for the conduct of law enforcement and
oversight activities.--For purposes'';
(ii) in subparagraph (A), as added by
subclause (I), by inserting ``, including, in
accordance with section 301(e)(1)(D) of the
Medicare and Medicaid Fighting Fraud and Abuse
to Save Taxpayers' Dollars Act, the Integrated
Data Repository under paragraph (1)'' before
the period at the end; and
(iii) by adding at the end the following
new subparagraph:
``(B) Access to reduce waste, fraud, and abuse.--
For purposes of reducing waste, fraud, and abuse, and
to the extent consistent with applicable information,
privacy, security, and disclosure laws, including the
regulations promulgated under the Health Insurance
Portability and Accountability Act of 1996 and section
552a of title 5, United States Code, and subject to any
information systems security requirements under such
laws or otherwise required by the Secretary, the
Secretary, in consultation with the Inspector General
of the Department of Health and Human Services, shall
allow appropriate State agency access to claims and
payment data of the Department of Health and Human
Services and its contractors related to titles XVIII,
XIX, and XXI, including, in accordance with section
301(e)(2)(A) of the Medicare and Medicaid Fighting
Fraud and Abuse to Save Taxpayers' Dollars Act, the
Integrated Data Repository under paragraph (1).''.
(f) General Protocols and Security.--
(1) In general.--The Secretary shall ensure that any data
provided to an entity or individual under the provisions of or
amendments made by this section is provided to such entity or
individual in accordance with protocols established by the
Secretary under paragraph (2). The Secretary shall consult with
the Inspector General of the Department of Health and Human
Services prior to implementing this subsection.
(2) Protocols.--
(A) In general.--The Secretary shall establish
protocols to ensure the secure transfer and storage of
any data provided to another entity or individual under
the provisions of or amendments made by this section.
(B) Consideration of recommendations of the
inspector general of the department of health and human
services.--In establishing protocols under subparagraph
(A), the Secretary shall take into account
recommendations submitted to the Secretary by the
Inspector General of the Department of Health and Human
Services with respect to the secure transfer and
storage of such data.
(g) Definitions.--In this section:
(1) Federal health care program.--The term ``Federal health
care program'' has the meaning given such term in section
1128B(f) of the Social Security Act (42 U.S.C. 1320a-7b(f)).
(2) Medicaid program.--The term ``Medicaid program'' means
the program under title XIX of the Social Security Act (42
U.S.C. 1396 et seq.).
(3) Medicare program.--The term ``Medicare program'' means
the program under title XVIII of the Social Security Act (42
U.S.C. 1395 et seq.).
(4) Medicare program safeguard contractors and other
oversight contractors.--The term ``Medicare program safeguard
contractors and other oversight contractors'' includes zone
program integrity contractors, program safeguard or integrity
contractors, recovery audit contractors under section 1893(h)
of the Social Security Act (42 U.S.C. 1395ddd(h)), special
investigative units at Medicare contractors (as defined in
section 1889(g) of the Social Security Act (42 U.S.C.
1395zz(g))), and any other oversight contractors designated by
the Secretary.
(5) 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)).
(6) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.
(7) State.--The term ``State'' includes the District of
Columbia, the Commonwealth of Puerto Rico, the Virgin Islands,
Guam, and American Samoa.
(8) Supplier.--The term ``supplier'' has the meaning given
such term in section 1861(d) of the Social Security Act (42
U.S.C. 1395x(d)).
SEC. 302. EXPANDING AUTOMATED PREPAYMENT REVIEW OF MEDICARE CLAIMS.
(a) Automated Prepayment Review.--
(1) In general.--Subject to subsection (b), the Secretary
shall establish automated prepayment review of all Medicare
claims under parts A and B of title XVIII of the Social
Security Act (42 U.S.C. 1395 et seq.) by not later than
September 30, 2012.
(2) Implementation.--The provisions of this section shall
be implemented in conjunction with, and as part of, any
predictive modeling and other analytics technologies
implemented under section 4241 of the Small Business Jobs Act
of 2010 (42 U.S.C. 1320a-7n), except that any requirement under
such section 4241 that conflicts with a requirement under this
section shall not apply to this section.
(b) Elements.--Such automated prepayment review shall include the
following:
(1) Program integrity system.--
(A) In general.--Subject to subparagraph (D), a
program integrity system under which relevant claims
under such parts A and B are compared in order to--
(i) identify errors or fraud under the
Medicare program, including--
(I) duplicate claims for items or
services; and
(II) claims where payment of
benefits under one such part is only
available if such payment is not
available under another such part; and
(ii) obtain such other information or
conduct such other analysis as the Secretary
determines is useful for program integrity
purposes.
(B) Implementation.--Not later than September 30,
2013, the Secretary shall ensure that all relevant
daily claims data under such parts A and B are compared
as part of such program integrity system.
(C) Plan for inclusion of part d claims data.--Not
later than September 30, 2013, the Secretary shall
establish a plan for including Medicare claims under
part D of such title XVIII (42 U.S.C. 1395w-101 et
seq.) for use in comparisons under such program
integrity system.
(D) No impact on prompt payment requirements.--In
no case shall the program integrity system under this
paragraph have any impact on prompt payment
requirements under such parts A and B, including such
requirements under sections 1816(c)(2) and 1842(c)(2)
of the Social Security Act (42 U.S.C. 1395h(c)(2);
1395u(c)(2)).
(2) Automated risk-based provider verification.--
(A) In general.--An automated risk-based
verification system for the purpose of verification and
analysis of providers of services and suppliers under
the Medicare program on an ongoing basis, including
during the period between the enrollment of the
provider of services or supplier under section 1866(j)
of the Social Security Act (42 U.S.C. 1395cc(j)) and
the revalidation (or any subsequent revalidation) of
such provider of services or supplier under such
section. Subject to subparagraph (C), such system shall
include criminal background checks for providers of
services and suppliers who the Secretary determines
present a high risk of waste, fraud, and abuse.
(B) Implementation.--The Secretary shall establish
the system under subparagraph (A) not later than
September 30, 2013.
(C) No duplication of screening under enrollment
process.--The system under subparagraph (A) shall be in
addition to and shall not duplicate any screening,
including any criminal background check, conducted
under section 1866(j)(2) of the Social Security Act (42
U.S.C. 1395cc(j)(2)).
(D) Prohibition on disclosure of risk-based data
and analysis.--The Secretary shall not disclose to the
public any data collected or analysis conducted under
the automated risk-based verification system under
subparagraph (A).
(3) Tracking rejected claims.--
(A) In general.--For the purpose of identifying and
analyzing potentially fraudulent and otherwise
inappropriate claims under the Medicare program, a
process for identifying and tracking, including by
provider of services or supplier, claims for payment
under the Medicare program that were rejected or denied
under the automated edit process of a medicare
administrative contractor under section 1874A of the
Social Security Act (42 U.S.C. 1395kk).
(B) Implementation.--The Secretary shall establish
the process under subparagraph (A) not later than
September 30, 2013.
(c) Definitions.--In this section:
(1) Medicare program.--The term ``Medicare program'' means
the program under title XVIII of the Social Security Act (42
U.S.C. 1395 et seq.).
(2) Automated prepayment review.--The term ``automated
prepayment review'' means screening using automated data
analysis and intelligent analysis prior to making payment. Such
term does not include prepayment medical review.
(3) Provider of services.--The term ``provider of
services'' has the meaning given that term in section 1861(u)
of such Act (42 U.S.C. 1395ww(u)).
(4) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.
(5) Supplier.--The term ``supplier'' has the meaning given
such term in section 1861(d) of such Act (42 U.S.C. 1395ww(d)).
SEC. 303. IMPROVING THE SHARING OF DATA BETWEEN THE FEDERAL GOVERNMENT
AND STATE MEDICAID PROGRAMS.
(a) In General.--The Secretary of Health and Human Services (in
this section referred to as the ``Secretary'') shall establish a plan
to encourage and facilitate the inclusion of States in the Medicare-
Medicaid Data Match Program (commonly referred to as the ``Medi-Medi
Program'') under section 1893(g) of the Social Security Act (42 U.S.C.
1395ddd(g)).
(b) Program Revisions To Improve Medi-Medi Data Match Program
Participation by States.--Section 1893(g)(1)(A) of the Social Security
Act (42 U.S.C. 1395ddd(g)(1)(A)) is amended--
(1) in the matter preceding clause (i), by inserting ``or
otherwise'' after ``eligible entities'';
(2) in clause (i)--
(A) by inserting ``to review claims data'' after
``algorithms''; and
(B) by striking ``service, time, or patient'' and
inserting ``provider, service, time, or patient'';
(3) in clause (ii)--
(A) by inserting ``to investigate and recover
amounts with respect to suspect claims'' after
``appropriate actions''; and
(B) by striking ``; and'' and inserting a
semicolon;
(4) in clause (iii), by striking the period and inserting
``; and''; and
(5) by adding at end the following new clause:
``(iv) furthering the Secretary's design,
development, installation, or enhancement of an
automated data system architecture--
``(I) to collect, integrate, and
assess data for purposes of program
integrity, program oversight, and
administration, including the Medi-Medi
Program; and
``(II) that improves the
coordination of requests for data from
States.''.
(c) Providing States With Data on Improper Payments Made for Items
or Services Provided to Dual Eligible Individuals.--
(1) In general.--The Secretary shall develop and implement
a plan that allows each State agency responsible for
administering a State plan for medical assistance under title
XIX of the Social Security Act access to relevant data on
improper or erroneous payments made under the Medicare program
under title XVIII of the Social Security Act (42 U.S.C. 1395 et
seq.) for health care items or services provided to dual
eligible individuals.
(2) Dual eligible individual defined.--In this section, the
term ``dual eligible individual'' means an individual who is
entitled to, or enrolled for, benefits under part A of title
XVIII of the Social Security Act (42 U.S.C. 1395c et seq.), or
enrolled for benefits under part B of title XVIII of such Act
(42 U.S.C. 1395j et seq.), and is eligible for medical
assistance under a State plan under title XIX of such Act (42
U.S.C. 1396 et seq.) or under a waiver of such plan.
SEC. 304. IMPROVING CLAIMS PROCESSING AND DETECTION OF FRAUD WITHIN THE
MEDICAID AND CHIP PROGRAMS.
(a) Medicaid.--Section 1903(i) of the Social Security Act (42
U.S.C. 1396b(i)), as amended by section 2001(a)(2)(B) of the Patient
Protection and Affordable Care Act (Public Law 111-148), is amended--
(1) in paragraph (25), by striking ``or'' at the end;
(2) in paragraph (26), by striking the period and inserting
``; or''; and
(3) by adding at the end the following new paragraph:
``(27) with respect to amounts expended for an item or
service for which medical assistance is provided under the
State plan or under a waiver of such plan unless the claim for
payment for such item or service contains--
``(A) a valid beneficiary identification number
that, for purposes of the individual who received such
item or service, has been determined by the State
agency to correspond to an individual who is eligible
to receive benefits under the State plan or waiver; and
``(B) a valid provider identifier that, for
purposes of the provider that furnished such item or
service, has been determined by the State agency to
correspond to a participating provider that is eligible
to receive payment for furnishing such item or service
under the State plan or waiver.''.
(b) CHIP.--Section 2107(e)(1)(I) of the Social Security Act (42
U.S.C. 1397gg(e)(1)(I)) is amended by striking ``and (17)'' and
inserting ``(17), and (27)''.
SEC. 305. REPORTS.
(a) Report to Congress on Plan for Implementation.--
(1) Report.--
(A) In general.--Not later than 270 days after the
date of enactment of this Act, the Secretary of Health
and Human Services, in consultation with the
Commissioner of Social Security and the Attorney
General, shall submit to Congress a report containing a
plan for implementing the provisions of and amendments
made by sections 301 through 304, including, with
respect to the implementation of section 303, the plan
described in subparagraph (B).
(B) Plan for increasing recovery of overpayments.--
The report submitted under subparagraph (A) shall
include a plan, developed by the Secretary of Health
and Human Services, in consultation with the inspector
General of the Department of Health and Human Services,
to increase the recovery of overpayments for health
care items or services provided to dual eligible
individuals (as defined in section 303(c)(2)).
(2) Inclusion in annual health care fraud and abuse control
account report.--Section 1817(k)(5) of the Social Security Act
(42 U.S.C. 1395i(k)(5)) is amended--
(A) in subparagraph (A), by striking ``and'' at the
end;
(B) in subparagraph (B), by striking the period at
the end and inserting ``; and''; and
(C) by adding at the end the following new
subparagraph:
``(C) effective beginning with the report submitted
January 1 following the date the report under section
306(a)(1) of the Medicare and Medicaid Fighting Fraud
and Abuse to Save Taxpayers' Dollars Act is submitted,
any updates to the plan included in the report under
such section 306(a)(1), including any potential
challenges to meeting the deadlines for implementation
of the provisions of and amendments made by sections
301 through 304 of such Act.''.
(b) Report to Congress on Interagency Cooperation and Data
Sharing.--Not later than 180 days after the date of enactment of this
Act, the Secretary of Health and Human Services, in consultation with
the Administrator of the Veterans Administration, the Secretary of
Defense, the Director of the Office of Personnel Management, and the
head of any other relevant Federal agency that administers a Federal
health care program, shall submit to Congress a report on the potential
of data sharing, including the sharing or data checking of Medicare
provider and Medicare beneficiary databases, to prevent and detect
potential fraud and improper payments under the Medicare program.
TITLE IV--IMPROVING CMS CONTRACTOR PERFORMANCE
SEC. 401. ESTABLISHING MEDICARE ADMINISTRATIVE CONTRACTOR ERROR
REDUCTION INCENTIVES.
(a) In General.--Section 1874A(b)(1)(D) of the Social Security Act
(42 U.S.C. 1395kk(b)(1)(D)) is amended--
(1) by striking ``quality.--The Secretary'' and inserting
``quality.--
``(i) In general.--Subject to clauses (ii)
and (iii), the Secretary''; and
(2) by inserting after clause (i), as added by paragraph
(1), the following new clauses:
``(ii) Improper payment error rate
reduction incentive plan.--The Secretary shall
establish a plan to provide incentives for
medicare administrative contractors to reduce
the improper payment error rates in their
jurisdictions.
``(iii) Contents of plan.--The plan
established under clause (ii)--
``(I) may include a sliding scale
of bonus payments and additional
incentives to medicare administrative
contractors that reduce the improper
payment error rates in their
jurisdictions to certain benchmark
levels; and
``(II) shall include penalties,
including substantial reductions in
award fee payments under award fee
contracts, for any medicare
administrative contractor that reaches
an upper end error threshold or other
threshold as determined by the
Secretary.''.
(b) Effective Date.--The amendments made by this section shall
apply to contracts entered into on or after the date that is 12 months
after the date of enactment of this Act and to current contracts
through modification when practicable.
SEC. 402. SEPARATING PROVIDER ENROLLMENT AND SCREENING FROM MEDICARE
ADMINISTRATIVE CONTRACTORS.
(a) In General.--Section 1866(j)(1) of the Social Security Act (42
U.S.C. 1395cc(j)(1)) is amended by adding at the end the following new
subparagraph:
``(D) Implementation.--The enrollment process
established under subparagraph (A) and the provider
screening under paragraph (2) shall be carried out
under one or more contracts with entities. Such
contracts shall be separate from any contract to serve
as a medicare administrative contractor under section
1874A.''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply to contracts entered into on or after the date that is 24 months
after the date of enactment of this Act and to current contracts
through modification when practicable.
SEC. 403. DEVELOPING MEASURABLE PERFORMANCE METRICS FOR MEDICARE
CONTRACTORS.
(a) Report.--Not later than 12 months after the date of enactment
of this Act, the Secretary of Health and Human Services (in this
section referred to as the ``Secretary'') shall submit to Congress a
report containing measurable metrics for improving Medicare contractor
performance, including Medicare administrative contractors under
section 1874A of the Social Security Act (42 U.S.C. 1395kk), program
safeguard contractors and other similar contractors, Medicare Drug
Integrity Contractors, qualified independent contractors with a
contract under section 1869(c) of the Social Security Act (42 U.S.C.
1395ff(c)), and other contractors that perform administrative or
oversight functions under the Medicare program under title XVIII of the
Social Security Act (42 U.S.C. 1395 et seq.).
(b) Contents of Report.--The report submitted under subsection (a)
shall include the Secretary's recommendations for the development of
measurable performance metrics for Medicare contractors (or updated and
revised measurable performance metrics), together with recommendations
for such legislation and administrative action as the Secretary
considers appropriate.
(c) Relationship to Government Performance and Results Act.--The
metrics submitted in the report under subsection (a) may include
performance goals or performance indicators established under the
provisions of and amendments made by the GPRA Modernization Act of 2010
(Public Law 111-352).
(d) Review by the Comptroller General.--Not later than 270 days
after the date on which the report is submitted under subsection (a),
the Comptroller General of the United States shall submit to Congress a
report containing a review of the report submitted under such
subsection.
TITLE V--OTHER PROVISIONS
SEC. 501. STRENGTHENING PENALTIES FOR THE ILLEGAL DISTRIBUTION OF A
MEDICARE, MEDICAID, OR CHIP BENEFICIARY IDENTIFICATION OR
BILLING PRIVILEGES.
Section 1128B(b) of the Social Security Act (42 U.S.C. 1320a-7b(b))
is amended by adding at the end the following:
``(4) Whoever knowingly, intentionally, and with the intent
to defraud purchases, sells or distributes, or arranges for the
purchase, sale, or distribution of a Medicare, Medicaid, or
CHIP beneficiary identification number or billing privileges
under title XVIII, title XIX, or title XXI, including a
provider identifier, shall be imprisoned for not more than 10
years or fined not more than $500,000 ($1,000,000 in the case
of a corporation), or both.''.
SEC. 502. PROVIDING IMPLEMENTATION FUNDING.
(a) In General.--For purposes of carrying out the provisions of and
amendments made by this Act, in addition to funds otherwise available,
there are appropriated to the Secretary of Health and Human Services
for the Centers for Medicare & Medicaid Services Program Management
Account, from amounts in the general fund of the Treasury not otherwise
appropriated, $75,000,000 for the period of fiscal years 2012 through
2016. Amounts appropriated under the preceding sentence shall remain
available until expended.
(b) Revision to the Medicare Improvement Fund.--Section
1898(b)(1)(B) of the Social Security Act (42 U.S.C. 1395iii(b)(1)(B))
is amended by striking ``$275,000,000'' and inserting ``$200,000,000''.
<all>
Introduced in House
Introduced in House
Referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, and the Judiciary, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, and the Judiciary, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, and the Judiciary, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Subcommittee on Health.
Referred to the Subcommittee on Health.
Referred to the Subcommittee on Crime, Terrorism, and Homeland Security.
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