Information technology system to detect fraud, waste, and abuse claims under the Veterans Community Care Program

(a)

In general

Subsection (f) of section 1703D of title 38, United States Code, is amended— (1)in paragraph (1)— (A)by striking paragraph (1) each place it appears and inserting subparagraph (A); (B)by inserting

(A)

before The Secretary; and (C)by redesignating paragraphs (2) and (3) as subparagraphs (B) and (C), respectively; and (2)by adding at the end the following new paragraph:

(2) (A)The Secretary shall use an information technology system to— (i)analyze a claim submitted to the Secretary— (I)by a health care entity or provider that furnishes hospital care, medical services, or extended care services under this chapter; and (II)through the health care claims enterprise solution (ii)detect whether such claim is a fraudulent claim, an overpayment, or other fraud, waste, or abuse. (B)The information technology system under this paragraph shall include the following functions: (i)Continuous monitoring of claims to detect patterns that may indicate fraud, waste, or abuse. (ii)Analysis of historical and real-time claims data to identify and predict potential fraudulent claims. (iii)Ready-made analytic models to identify and analyze fraudulent claims. (iv)Post-payment analysis for overuse of services or other practices that create unnecessary costs to the Department. (v)Integration with existing claims processing systems and technologies of the Department. (vi)Logging, storage, analysis, and reports regarding the nature, frequency, and financial impact of detected fraudulent claims. (vii)Identification of, and machine learning that is based on, patterns of fraudulent claims in order to reduce false positives and predict new forms of fraud. (viii)Updates to detect new models of fraud, waste and abuse. (ix)Any other function determined necessary by the Secretary. (C)To carry out this paragraph, the Secretary shall use funds from the Department of Veterans Affairs franchise fund established under title I of Public Law 104–204 (38 U.S.C. 301 note). (D)Not later than two years after the date of the enactment of the FRAUD Act of 2025 and annually thereafter through the day described in subparagraph (E), the Secretary shall submit to the Committees on Veterans' Affairs of the Senate and House of Representatives a report regarding the operation of such information technology system during the preceding year. Each such report shall include the following elements: (i)The effectiveness of the information technology system in performing the functions described in subparagraph (B). (ii)The estimated savings to the Department arising from the use of the information technology system. (iii)Any plans to enhance, modify, or add new capabilities to the information technology system. (E)This paragraph shall cease to be effective on the day that is seven years after the date of the enactment of the FRAUD Act of 2025. (F)In this paragraph: (i)The term Community Care Network means a network established under section 1703(h) of this title. (ii)The term health care claims enterprise solution means the information technology used by the Secretary to process a claim submitted under this chapter by a health care entity or provider that is not part of a Community Care Network.

(b)

Implementation date

The Secretary shall carry out the amendments made by this section not later than one year after the date of the enactment of this Act.