[Congressional Bills 104th Congress]
[From the U.S. Government Publishing Office]
[S. 762 Introduced in Senate (IS)]







104th CONGRESS
  1st Session
                                 S. 762

 To implement General Accounting Office recommendations regarding the 
  use of commercial software to detect billing code abuse in medicare 
               claims processing, and for other purposes.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                  May 5 (legislative day, May 1), 1995

  Mr. Harkin introduced the following bill; which was read twice and 
                  referred to the Committee on Finance

_______________________________________________________________________

                                 A BILL


 
 To implement General Accounting Office recommendations regarding the 
  use of commercial software to detect billing code abuse in medicare 
               claims processing, and for other purposes.
    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 ``Medicare Billing Abuse Prevention 
Act of 1995''.

SEC. 2. FINDINGS.

    The Congress finds that--
            (1) the General Accounting Office has reported that the use 
        of commercial software to detect billing code abuse by medicare 
        supplementary medical insurance program carriers may save the 
        taxpayers $2,000,000 per day; and
            (2) prompt use of such software may be impeded by 
        regulatory requirements which are not related to efficient 
        implementation of the medicare program.

SEC. 3. IMPLEMENTATION OF GENERAL ACCOUNTING OFFICE RECOMMENDATIONS 
              REGARDING MEDICARE CLAIMS PROCESSING.

    (a) In General.--Not later than 90 days after the date of the 
enactment of this Act, the Secretary shall, by regulation, contract, 
change order, or otherwise, require medicare carriers to acquire 
commercial automatic data processing equipment (in this Act referred to 
as ``ADPE'') meeting the requirements of section 4 to process medicare 
part B claims for the purpose of identifying billing code abuse.
    (b) Supplementation.--Any ADPE acquired in accordance with 
subsection (a) shall be used as a supplement to any other ADPE used in 
claims processing by medicare carriers.
    (c) Standardization.--In order to ensure uniformity, the Secretary 
may require that medicare carriers that use a common claims processing 
system acquire common ADPE in implementing subsection (a).
    (d) Implementation Date.--Any ADPE acquired in accordance with 
subsection (a) shall be in use by medicare carriers not later than 180 
days after the date of the enactment of this Act.

SEC. 4. MINIMUM SOFTWARE REQUIREMENTS.

    (a) In General.--The requirements described in this section are as 
follows:
            (1) The ADPE shall be a commercial item.
            (2) The ADPE shall surpass the capability of ADPE used in 
        the processing of medicare part B claims for identification of 
        code manipulation on the day before the date of the enactment 
        of this Act.
            (3) The ADPE shall be capable of being modified to--
                    (A) satisfy pertinent statutory requirements of the 
                medicare program; and
                    (B) conform to general policies of the Health Care 
                Financing Administration regarding claims processing.
    (b) Minimum Standards.--Nothing in this Act shall be construed as 
preventing the use of ADPE which exceeds the minimum requirements 
described in subsection (a).

SEC. 5. DISCLOSURE.

    (a) In General.--Notwithstanding any other provision of law, and 
except as provided in subsection (b), any ADPE or data related thereto 
acquired by medicare carriers in accordance with section 3(a) shall not 
be subject to public disclosure.
    (b) Exception.--The Secretary may authorize the public disclosure 
of any ADPE or data related thereto acquired by medicare carriers in 
accordance with section 3(a) if the Secretary determines that--
            (1) release of such information is in the public interest; 
        and
            (2) the information to be released is not protected from 
        disclosure under section 552(b) of title 5, United States Code.

SEC. 6. REVIEW AND MODIFICATION OF REGULATIONS.

    Not later than 30 days after the date of the enactment of this Act, 
the Secretary shall order a review of existing regulations, guidelines, 
and other guidance governing medicare payment policies and billing code 
abuse to determine if revision of or addition to those regulations, 
guidelines, or guidance is necessary to maximize the benefits to the 
Federal Government of the use of ADPE acquired pursuant to section 3.

SEC. 7. DEFINITIONS.

    For purposes of this Act--
            (1) The term ``automatic data processing equipment'' (ADPE) 
        has the same meaning as in section 111(a)(2) of the Federal 
        Property and Administrative Services Act of 1949 (40 U.S.C. 
        759(a)(2)).
            (2) The term ``billing code abuse'' means the submission to 
        medicare carriers of claims for services that include procedure 
        codes that do not appropriately describe the total services 
        provided or otherwise violate medicare payment policies.
            (3) The term ``commercial item'' has the same meaning as in 
        section 4(12) of the Office of Federal Procurement Policy Act 
        (41 U.S.C. 403(12)).
            (4) The term ``medicare part B'' means the supplementary 
        medical insurance program authorized under part B of title 
        XVIII of the Social Security Act (42 U.S.C. 1395j-1395w-4).
            (5) The term ``medicare carrier'' means an entity that has 
        a contract with the Health Care Financing Administration to 
        determine and make medicare payments for medicare part B 
        benefits payable on a charge basis and to perform other related 
        functions.
            (6) The term ``payment policies'' means regulations and 
        other rules that govern billing code abuses such as unbundling, 
        global service violations, double billing, and unnecessary use 
        of assistants at surgery.
            (7) The term ``Secretary'' means the Secretary of Health 
        and Human Services.
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