Stop Schemes and Crimes Against Medicare and Seniors (Stop SCAMS) Act - Amends title XI of the Social Security Act with respect to standards for financial and administrative transactions and their data elements to enable the electronic exchange of health information.
Requires the Secretary of Health and Human Services (HHS) to adopt standards that: (1) ensure that any entity producing and transmitting valid transactions that include code sets for appropriate data elements is subject to a consistent, industry-wide framework that supports a seamless transition to new and modified code sets; and (2) establish an end-to-end testing procedure for new and modified code sets that shall require the participation of any entity producing and transmitting valid transactions that use the new or modified code set.
Prohibits the Secretary from adopting a new or modified code set unless the Secretary: (1) assesses its impact on fraud prevention and pre-payment review, determines that anti-fraud edits work as intended, and confirms that a plan is in place to ensure continuing effective detection of fraud following the adoption of the code set; (2) ensures that the end-to-end testing procedure established has been completed; and (3) completes end-to-end testing with any federal government entity that produces and transmits valid transactions that include the code set with private sector tracking partners. Exempts routine, regularly scheduled updates to existing code sets from such prohibition.
Directs the Secretary, with respect to information supplied to it by a disclosing entity about those with an ownership or control interest in the entity, to verify such information in a specified manner and confirm the accuracy of any Social Security account number or employer identification number.
Holds immune from civil liability (in a safe harbor) any non-governmental entity participating in a Healthcare Fraud Prevention Partnership, including private insurers, for sharing information about potentially fraudulent providers with each other, HHS, the Department of Justice (DOJ), any other federal or state law enforcement agency, any federal or state agency contractor, and another Partnership participant.
Directs the Medicare Payment Advisory Commission (MEDPAC) to study administrative efforts to strengthen program integrity in the Medicare program.
Amends the Small Business Jobs Act of 2010, with respect to the use of predictive modeling and other analytics technologies to identify and prevent waste, fraud, and abuse in the Medicare fee-for-service program, to require predictive analytics technologies to capture outcome information on civil recoveries, administrative actions, and criminal convictions for fraud.
[Congressional Bills 113th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5732 Introduced in House (IH)]
113th CONGRESS
2d Session
H. R. 5732
To amend title XVIII of the Social Security Act to crack down on fraud
in the Medicare program to protect seniors, people with disabilities,
and taxpayers.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
November 18, 2014
Mr. Deutch (for himself and Mr. Roskam) introduced the following bill;
which was referred to the Committee on Energy and Commerce, and in
addition to the Committee on Ways and Means, 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 title XVIII of the Social Security Act to crack down on fraud
in the Medicare program to protect seniors, people with disabilities,
and taxpayers.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Stop Schemes and Crimes Against
Medicare and Seniors (Stop SCAMS) Act''.
SEC. 2. ENSURING THAT NEW MEDICAL CODING SYSTEMS DO NOT COMPROMISE
FRAUD PREVENTION EFFORTS.
(a) In General.--Section 1173(c) of the Social Security Act (42
U.S.C. 1320d-2(c)) is amended--
(1) in paragraph (1)--
(A) in subparagraph (A), by striking ``; or'' and
inserting ``or, if no code sets for such data elements
have been developed, establish code sets for the data
elements;''; and
(B) by striking subparagraph (B) and adding the
following new subparagraphs:
``(B) ensure that any entity producing and
transmitting valid transactions that include code sets
are subject to a consistent, industry-wide framework
that supports a seamless transition to new and modified
code sets; and
``(C) establish, by a rule promulgated after notice
and an opportunity for a hearing on the record, an end-
to-end testing procedure for new and modified code sets
that shall require the participation of any entity
producing and transmitting valid transactions that use
such new or modified code set.''; and
(2) by adding at the end the following paragraphs:
``(3) Adopting new and modified code sets.--The Secretary
shall not adopt a new or modified code set unless the
Secretary--
``(A) assesses the impact of the code set on fraud
prevention and pre-payment review, determines that
anti-fraud edits work as intended, and confirms that a
plan is in place to ensure continuing effective
detection of fraud following the adoption of the code
set;
``(B) ensures that the end-to-end testing procedure
established by the Secretary under paragraph (1) has
been completed; and
``(C) completes end-to-end testing with any Federal
Government entity that produces and transmits valid
transactions that include the code set with private
sector tracking partners.
``(4) Routine updates to existing code sets.--Paragraph (3)
shall not apply to routine, regularly scheduled updates to
existing code sets.''.
(b) Effective Date.--The amendments made by this section shall be
effective as of October 1, 2015.
SEC. 3. VERIFICATION OF PROVIDER OWNERSHIP INTERESTS.
(a) In General.--Section 1124(c) of the Social Security Act (42
U.S.C. 1320a-3(c)) is amended--
(1) by redesignating paragraph (5) as paragraph (6); and
(2) by inserting after paragraph (4) the following
paragraph:
``(5) Verification of information.--
``(A) In general.--With respect to information
supplied by a disclosing entity under subsections (a)
and (b), the Secretary shall--
``(i) verify such information by comparing
it to available data on the provider collected
through disclosures made to the Secretary under
section 1128G(a)(2), or, in the case of a
disclosing entity to which section 1128G(a)(2)
does not apply, verify such information through
comparison with at least one other public or
private database which contains information as
to the identity of each person with an
ownership or control interest in the entity;
and
``(ii) confirm the accuracy of any social
security account number or employer
identification number supplied under subsection
(a) by verifying--
``(I) each social security account
number with the Commissioner of Social
Security; and
``(II) each employer identification
number with the Secretary of the
Treasury.
``(B) Discrepancies.--If the comparison described
in subparagraph (A)(i) reveals a discrepancy between
information supplied by a disclosing entity under
subsections (a) and (b) and available data on the
provider collected through disclosures made to the
Secretary under section 1128G(a)(2), the Secretary
shall independently verify the accuracy of such data
collected under section 1128G(a)(2) before taking any
action against a provider based on such discrepancy.''.
(b) Effective Date.--The amendments made by this section shall be
effective as of the date that is 1 year after the date of enactment of
this Act.
SEC. 4. SUPPORTING PUBLIC AND PRIVATE INFORMATION SHARING TO PREVENT
HEALTH CARE FRAUD.
(a) Definitions.--In this section:
(1) Healthcare fraud prevention partnership; partnership.--
The terms ``Healthcare Fraud Prevention Partnership'' and
``Partnership'' mean the information sharing partnership
established between the Department of Health and Human
Services, the Department of Justice, and other public and
private stakeholders, including private insurers, under the
authority of section 1128C(a)(2) of the Social Security Act (42
U.S.C. 1320a-7c(a)(2)) for the purpose of detecting and
preventing health care fraud.
(2) Private insurer.--The term ``private insurer'' has the
meaning given the term ``health insurance issuer'' under
section 2791(b)(2) of the Public Health Service Act (42 U.S.C.
300GG-91(b)(2)).
(b) Safe Harbor for the Sharing of Information.--
(1) General immunity.--
(A) In general.--A non-governmental entity
participating in the Partnership (including a private
insurer) that--
(i) provides data or information described
in clause (i) or (ii) of subparagraph (B) to
the Department of Health and Human Services,
the Department of Justice, any other Federal or
State law enforcement agency, any contractor of
such Department or agency, or another entity
participating in the Partnership (including a
private insurer); or
(ii) uses such data or information as
permitted by this subsection,
shall be immune from civil liability with respect to
the provision or authorized use of such data or
information.
(B) Data or information.--
(i) Data.--The data described in this
clause is aggregated claims data or other
information described in clause (ii) that does
not include individually identifiable
information with respect to any health care
provider, supplier, or beneficiary, whether or
not analysis of such information results in the
identification of a health care provider,
supplier, or other person or organization as
having committed fraud or having committed acts
suspected of being fraudulent.
(ii) Information.--The information
described in this clause is information
concerning fraud or suspected fraudulent acts
that identifies a specific health care
provider, supplier, or other person or
organization if the provider, supplier, or
other person or organization so identified--
(I) is the subject of a bona fide
fraud investigation conducted by the
entity participating in the
Partnership, including a private
insurer, that is providing the
information;
(II) is the subject of a fraud-
related allegation that has been filed
by or received by the entity
participating in the Partnership,
including a private insurer, that is
providing the information; or
(III) has been convicted of a
fraud-related offense.
(2) Limitation.--The immunity described in paragraph (1)
shall apply only where--
(A) the data or information involved was provided
in good faith and without malice; and
(B) the data or information provided is true, based
on a reasonable belief, to the knowledge of the person
providing the information, or if false, the information
is provided without knowledge of, and without reckless
disregard for, its falsity.
(3) Use of partnership data or information.--For purposes
of this subsection, data or information relating to a specific
provider or supplier received by a private insurer solely
through the Partnership shall be used, with respect to such
provider or supplier, only for the purpose of informing
decisionmaking by the private insurer related to fraud
investigations, including whether to conduct such an
investigation. Nothing in the preceding sentence shall prevent
a private insurer or other entity participating in the
Partnership from taking other actions, not specific to such
provider or supplier, based on such data or information.
(c) Report.--Not later than October 1 of each calendar year that
begins after the date of enactment of this Act, the Secretary of Health
and Human Services shall submit to the Special Committee on Aging, the
Committee on Finance, and the Committee on Homeland Security and
Governmental Affairs of the Senate, and the Committee on Ways and Means
and the Committee on Energy and Commerce of the House of
Representatives, a report that describes the activities of the
Healthcare Fraud Prevention Partnership. Such report shall include--
(1) a description of how input was obtained from private
insurers regarding the appropriate usage of data shared through
the Healthcare Fraud Prevention Partnership; and
(2) plans for the Partnership to be expanded to encompass a
representative sample of national private insurers and to
include health care provider organizations.
SEC. 5. MEDPAC STUDY AND REPORT.
(a) Study.--The Medicare Payment Advisory Commission shall conduct
a study on administrative efforts to strengthen program integrity in
the Medicare program. Such study may include--
(1) an evaluation of ways to detect fraudulent claims
before payment is made;
(2) a review of the efficiency and effectiveness of post-
payment recovery methods;
(3) analysis by the Centers for Medicare & Medicaid
Services and public reporting of claims and spending patterns;
and
(4) a review of the organizational structure and resources
of the Centers for Medicare & Medicaid Services as they relate
to program integrity.
(b) Report.--Not later than June 15, 2016, the Medicare Payment
Advisory Commission shall submit to Congress a report on the study
conducted under subsection (a), together with recommendations for such
legislative and administrative action as the Commission determines
appropriate.
SEC. 6. ABILITY TO MEASURE FRAUD PREVENTION EFFORTS.
Section 4241 of the Small Business Jobs Act of 2010 (42 U.S.C.
1320a-7m) is amended--
(1) in subsection (b)(4), by inserting ``and on civil
recoveries, administrative actions, and criminal convictions
for fraud'' after ``reimbursement''; and
(2) in subsection (c), by adding at the end the following
paragraph:
``(7) Implementation of amendments.--The Secretary shall
implement amendments made to this subsection by the Stop
Schemes and Crimes Against Medicare and Seniors (Stop SCAMS)
Act not later than 6 months after the date of enactment of such
Act. If the Secretary determines that new technology or data
processing systems are required to carry out such amendments,
the Secretary shall issue a request for proposals to carry out
such amendments not later than 6 months after the enactment of
such Act, and the contractors selected under such request for
proposal shall implement such amendments not later than 12
months after the date of enactment of such Act.''.
<all>
Introduced in House
Introduced in House
Referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, 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 Committee on Ways and Means, 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.
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